- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.56 / $238.14 / $521.29
| Facility | | $158.56 | $238.14 | $521.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.56 / $158.56 / $158.56
| Professional | | $158.56 | $158.56 | $158.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.78 / $236.32 / $477.40
| Facility | | $53.78 | $236.32 | $477.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.44 / $155.44 / $158.55
| Professional | | $155.44 | $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
- $158.19 / $158.19 / $158.19
| Professional | | $158.19 | $158.19 | $158.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.91 / $155.44 / $172.55
| Professional | | $139.91 | $155.44 | $172.55 |