- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.04 / $147.04 / $158.44
| Facility | | $147.04 | $147.04 | $158.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.87 / $53.87 / $53.87
| Professional | | $53.87 | $53.87 | $53.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.87 / $27.45 / $71.62
| Facility | | $21.87 | $27.45 | $71.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.87 / $53.87 / $53.87
| Professional | | $53.87 | $53.87 | $53.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.87 / $53.87 / $53.87
| Facility | | $53.87 | $53.87 | $53.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.87 / $53.87 / $53.87
| Professional | | $53.87 | $53.87 | $53.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.60 / $22.60 / $27.37
| Professional | | $22.60 | $22.60 | $27.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.04 / $147.04 / $158.44
| Facility | | $147.04 | $147.04 | $158.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.87 / $53.87 / $158.44
| Professional | | $53.87 | $53.87 | $158.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.60 / $52.82 / $76.59
| Professional | | $22.60 | $52.82 | $76.59 |