- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $371.54 / $371.54
| Facility | | $346.74 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $123.03 / $125.89
| Professional | | $120.23 | $123.03 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.89 / $151.36 / $416.87
| Facility | | $125.89 | $151.36 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $128.82 / $128.82
| Professional | | $125.89 | $128.82 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $128.82 / $147.91
| Facility | | $128.82 | $128.82 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $128.82 / $128.82
| Professional | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $128.82 / $154.88
| Professional | | $128.82 | $128.82 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $371.54
| Facility | | $346.74 | $346.74 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $125.89 / $151.36
| Professional | | $120.23 | $125.89 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $128.82 / $218.78
| Professional | | $125.89 | $128.82 | $218.78 |