- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.21 / $210.54 / $486.37
| Facility | | $163.21 | $210.54 | $486.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $164.25 / $197.48
| Professional | | $164.25 | $164.25 | $197.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.86 / $94.46 / $167.51
| Facility | | $58.86 | $94.46 | $167.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.51 / $167.51 / $170.86
| Professional | | $167.51 | $167.51 | $170.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.96 / $154.96 / $164.25
| Facility | | $154.96 | $154.96 | $164.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $164.25 / $164.25
| Professional | | $164.25 | $164.25 | $164.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.83 / $164.25 / $189.05
| Professional | | $147.83 | $164.25 | $189.05 |