- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.97 / $162.97 / $772.38
| Facility | | $162.97 | $162.97 | $772.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.72 / $162.97 / $196.09
| Professional | | $143.72 | $162.97 | $196.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.81 / $166.14 / $203.72
| Professional | | $148.81 | $166.14 | $203.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.75 / $153.75 / $203.81
| Facility | | $153.75 | $153.75 | $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
- Facility
- Modifier
- Low / Median / High Price
- $145.09 / $179.28 / $379.83
| Facility | | $145.09 | $179.28 | $379.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $187.43 / $218.36
| Professional | | $162.97 | $187.43 | $218.36 |