- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.02 / $157.02 / $169.20
| Facility | | $157.02 | $157.02 | $169.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.53 / $57.53 / $57.53
| Professional | | $57.53 | $57.53 | $57.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.38 / $174.38 / $174.38
| Facility | | $174.38 | $174.38 | $174.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.52 / $57.52 / $57.52
| Professional | | $57.52 | $57.52 | $57.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.53 / $57.53 / $57.53
| Facility | | $57.53 | $57.53 | $57.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.53 / $57.53 / $57.53
| Professional | | $57.53 | $57.53 | $57.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.53 / $57.53 / $69.67
| Professional | | $57.53 | $57.53 | $69.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.02 / $157.02 / $169.20
| Facility | | $157.02 | $157.02 | $169.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.53 / $57.53 / $169.20
| Professional | | $57.53 | $57.53 | $169.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.40 / $56.40 / $81.78
| Professional | | $56.40 | $56.40 | $81.78 |