- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $144.54
| Facility | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $144.54 / $173.78
| Professional | | $141.25 | $144.54 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $154.88 / $251.19
| Facility | | $144.54 | $154.88 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $676.08
| Professional | | $162.18 | $162.18 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $162.18
| Facility | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $154.88 / $162.18
| Professional | | $104.71 | $154.88 | $162.18 |