- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.67 / $104.67 / $177.93
| Facility | | $104.67 | $104.67 | $177.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.67 / $104.67 / $163.28
| Professional | | $104.67 | $104.67 | $163.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.80 / $100.80 / $100.80
| Professional | | $100.80 | $100.80 | $100.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.07 / $115.07 / $115.07
| Facility | | $115.07 | $115.07 | $115.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.07 / $115.07 / $115.07
| Professional | | $115.07 | $115.07 | $115.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.30 / $93.02 / $123.14
| Professional | | $89.30 | $93.02 | $123.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.53 / $123.14 / $159.41
| Facility | | $72.53 | $123.14 | $159.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.10 / $112.51 / $151.22
| Facility | | $110.10 | $112.51 | $151.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.10 / $112.51 / $151.22
| Professional | | $110.10 | $112.51 | $151.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.74 / $123.14 / $129.30
| Professional | | $102.74 | $123.14 | $129.30 |