- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.81 / $154.81 / $160.85
| Facility | | $154.81 | $154.81 | $160.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.19 / $142.97 / $175.36
| Professional | | $108.19 | $142.97 | $175.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.82 / $241.26 / $241.26
| Facility | | $53.82 | $241.26 | $241.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.51 / $159.56 / $183.26
| Professional | | $145.51 | $159.56 | $183.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.77 / $153.77 / $153.77
| Facility | | $153.77 | $153.77 | $153.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.59 / $153.77 / $257.35
| Professional | | $18.59 | $153.77 | $257.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.27 / $105.46 / $170.63
| Professional | | $77.27 | $105.46 | $170.63 |