- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.44 / $158.56 / $373.08
| Facility | | $155.44 | $158.56 | $373.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.03 / $154.83 / $158.56
| Professional | | $152.03 | $154.83 | $158.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.78 / $127.57 / $245.16
| Facility | | $53.78 | $127.57 | $245.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.22 / $155.44 / $158.55
| Professional | | $149.22 | $155.44 | $158.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.56 / $158.56 / $158.56
| Facility | | $158.56 | $158.56 | $158.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.56 / $158.56 / $158.56
| Professional | | $158.56 | $158.56 | $158.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.44 / $155.44 / $162.72
| Professional | | $155.44 | $155.44 | $162.72 |