- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $381.06 / $381.06 / $410.63
| Facility | | $381.06 | $381.06 | $410.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $170.82 / $197.48
| Professional | | $164.25 | $170.82 | $197.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.08 / $182.60 / $520.51
| Facility | | $146.08 | $182.60 | $520.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $164.25 / $170.45
| Professional | | $164.25 | $164.25 | $170.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.51 / $164.25 / $164.25
| Facility | | $152.51 | $164.25 | $164.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $164.25 / $164.25
| Professional | | $164.25 | $164.25 | $164.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $164.25 / $164.25
| Professional | | $164.25 | $164.25 | $164.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $381.06 / $381.06 / $410.63
| Facility | | $381.06 | $381.06 | $410.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.84 / $172.47 / $333.09
| Professional | | $164.84 | $172.47 | $333.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $164.25 / $238.16
| Professional | | $164.25 | $164.25 | $238.16 |