- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.83 / $149.83 / $427.83
| Facility | | $149.83 | $149.83 | $427.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.83 / $149.83 / $149.83
| Professional | | $149.83 | $149.83 | $149.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.77 / $246.26 / $454.32
| Facility | | $157.77 | $246.26 | $454.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.96 / $149.96 / $149.96
| Professional | | $149.96 | $149.96 | $149.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.66 / $164.66 / $164.66
| Facility | | $164.66 | $164.66 | $164.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.66 / $164.66 / $164.66
| Professional | | $164.66 | $164.66 | $164.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.63 / $158.63 / $158.63
| Facility | | $158.63 | $158.63 | $158.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.63 / $176.27 / $176.27
| Professional | | $158.63 | $176.27 | $176.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.02 / $158.63 / $162.16
| Professional | | $147.02 | $158.63 | $162.16 |