- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.38 / $142.38 / $142.38
| Facility | | $142.38 | $142.38 | $142.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.38 / $142.38 / $151.27
| Professional | | $142.38 | $142.38 | $151.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.29 / $83.46 / $83.46
| Professional | | $79.29 | $83.46 | $83.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.27 / $151.27 / $151.27
| Facility | | $151.27 | $151.27 | $151.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $173.17 / $206.15
| Professional | | $134.88 | $173.17 | $206.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.38 / $224.96 / $270.52
| Facility | | $142.38 | $224.96 | $270.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.79 / $161.79 / $177.97
| Professional | | $161.79 | $161.79 | $177.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.88 / $134.88 / $213.46
| Facility | | $134.88 | $134.88 | $213.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $173.17 / $206.15
| Professional | | $134.88 | $173.17 | $206.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.69 / $161.79 / $177.97
| Professional | | $153.69 | $161.79 | $177.97 |