- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.59 / $182.85 / $288.85
| Professional | | $164.59 | $182.85 | $288.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.33 / $186.33 / $186.33
| Facility | | $186.33 | $186.33 | $186.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.27 / $184.87 / $308.11
| Facility | | $155.27 | $184.87 | $308.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.59 / $164.59 / $164.59
| Professional | | $164.59 | $164.59 | $164.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.27 / $184.87 / $308.11
| Facility | | $155.27 | $184.87 | $308.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.59 / $164.59 / $164.59
| Professional | | $164.59 | $164.59 | $164.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.36 / $164.59 / $253.19
| Professional | | $156.36 | $164.59 | $253.19 |