- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.35 / $562.35 / $18,512.36
| Facility | | $562.35 | $562.35 | $18,512.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.03 / $174.75 / $181.68
| Professional | | $173.03 | $174.75 | $181.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.55 / $172.55 / $184.79
| Facility | | $172.55 | $172.55 | $184.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.03 / $173.03 / $173.03
| Professional | | $173.03 | $173.03 | $173.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.03 / $173.03 / $173.03
| Facility | | $173.03 | $173.03 | $173.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.03 / $173.03 / $173.03
| Professional | | $173.03 | $173.03 | $173.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.03 / $173.03 / $192.62
| Professional | | $173.03 | $173.03 | $192.62 |