- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.82 / $173.78 / $6,456.54
| Facility | | $169.82 | $173.78 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $173.78 / $1,258.93
| Professional | | $169.82 | $173.78 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $186.21
| Facility | | $186.21 | $186.21 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $186.21 / $204.17
| Professional | | $141.25 | $186.21 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $173.78 / $218.78
| Professional | | $169.82 | $173.78 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.88 / $169.82 / $407.38
| Facility | | $154.88 | $169.82 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $173.78 / $380.19
| Professional | | $154.88 | $173.78 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.82 / $169.82 / $169.82
| Facility | | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $173.78 / $204.17
| Professional | | $169.82 | $173.78 | $204.17 |