- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.82 / $175.82 / $202.19
| Facility | | $175.82 | $175.82 | $202.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.21 / $199.34 / $226.53
| Professional | | $181.21 | $199.34 | $226.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.96 / $181.22 / $181.22
| Facility | | $170.96 | $181.22 | $181.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.22 / $181.22 / $181.22
| Professional | | $181.22 | $181.22 | $181.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.34 / $226.53 / $323.94
| Facility | | $199.34 | $226.53 | $323.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.22 / $181.22 / $226.53
| Professional | | $181.22 | $181.22 | $226.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.46 / $266.37 / $455.05
| Facility | | $186.46 | $266.37 | $455.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.47 / $217.47 / $226.53
| Professional | | $217.47 | $217.47 | $226.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.22 / $181.22 / $285.36
| Professional | | $181.22 | $181.22 | $285.36 |