- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.42 / $164.42 / $164.42
| Facility | | $164.42 | $164.42 | $164.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.42 / $180.86 / $198.95
| Professional | | $164.42 | $180.86 | $198.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.86 / $288.69 / $526.14
| Facility | | $180.86 | $288.69 | $526.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.16 / $235.16 / $235.16
| Professional | | $235.16 | $235.16 | $235.16 |
- 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
- $154.57 / $168.44 / $235.12
| Facility | | $154.57 | $168.44 | $235.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.32 / $180.86 / $269.64
| Professional | | $123.32 | $180.86 | $269.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.42 / $194.02 / $235.16
| Professional | | $164.42 | $194.02 | $235.16 |