- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.46 / $161.46 / $169.54
| Facility | | $161.46 | $161.46 | $169.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.46 / $169.54 / $172.67
| Professional | | $161.46 | $169.54 | $172.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.37 / $172.37 / $172.37
| Facility | | $172.37 | $172.37 | $172.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.32 / $172.37 / $172.37
| Professional | | $51.32 | $172.37 | $172.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.07 / $146.35 / $230.89
| Facility | | $83.07 | $146.35 | $230.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.21 / $181.60 / $184.68
| Professional | | $146.21 | $181.60 | $184.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.21 / $169.29 / $184.68
| Professional | | $146.21 | $169.29 | $184.68 |