- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.42 / $164.42 / $246.51
| Facility | | $164.42 | $164.42 | $246.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.42 / $164.42 / $200.59
| Professional | | $164.42 | $164.42 | $200.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.42 / $271.07 / $522.77
| Facility | | $164.42 | $271.07 | $522.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.53 / $190.53 / $225.12
| Professional | | $190.53 | $190.53 | $225.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $219.62 / $219.62 / $219.62
| Facility | | $219.62 | $219.62 | $219.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.62 / $219.62 / $219.62
| Professional | | $219.62 | $219.62 | $219.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.76 / $140.76 / $172.00
| Facility | | $140.76 | $140.76 | $172.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.42 / $194.02 / $235.16
| Professional | | $164.42 | $194.02 | $235.16 |