- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.47 / $171.74 / $327.62
| Facility | | $155.47 | $171.74 | $327.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $162.97 / $249.86
| Professional | | $162.97 | $162.97 | $249.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.42 / $169.42 / $169.42
| Facility | | $169.42 | $169.42 | $169.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.88 / $169.42 / $169.42
| Professional | | $162.88 | $169.42 | $169.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.75 / $203.81 / $203.81
| Facility | | $153.75 | $203.81 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.81 / $203.81 / $203.81
| Professional | | $203.81 | $203.81 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.83 / $174.01 / $218.36
| Professional | | $154.83 | $174.01 | $218.36 |