- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.88 / $168.60 / $168.60
| Facility | | $134.88 | $168.60 | $168.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $134.88 / $168.60
| Professional | | $134.88 | $134.88 | $168.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.21 / $174.36 / $232.76
| Facility | | $148.21 | $174.36 | $232.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.52 / $146.52 / $146.52
| Professional | | $146.52 | $146.52 | $146.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.31 / $143.31 / $143.31
| Facility | | $143.31 | $143.31 | $143.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.31 / $143.31 / $143.31
| Professional | | $143.31 | $143.31 | $143.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.88 / $168.60 / $201.23
| Facility | | $134.88 | $168.60 | $201.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.50 / $140.50 / $165.23
| Professional | | $140.50 | $140.50 | $165.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.50 / $140.50 / $168.60
| Professional | | $140.50 | $140.50 | $168.60 |