- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.79 / $177.79 / $177.79
| Facility | | $177.79 | $177.79 | $177.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $163.24 / $177.79
| Professional | | $161.62 | $163.24 | $177.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.22 / $321.81 / $795.84
| Facility | | $136.22 | $321.81 | $795.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.35 / $170.27 / $402.27
| Professional | | $138.35 | $170.27 | $402.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $161.62
| Facility | | $161.62 | $161.62 | $161.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $161.62
| Professional | | $161.62 | $161.62 | $161.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.84 / $193.01 / $383.67
| Facility | | $160.84 | $193.01 | $383.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.84 / $164.84 / $357.70
| Professional | | $164.84 | $164.84 | $357.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $161.62
| Professional | | $161.62 | $161.62 | $161.62 |