- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.49 / $202.49 / $218.20
| Facility | | $202.49 | $202.49 | $218.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.78 / $105.20 / $105.20
| Professional | | $90.78 | $105.20 | $105.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $84.46 / $106.02 / $276.58
| Facility | | $84.46 | $106.02 | $276.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.28 / $87.28 / $87.28
| Professional | | $87.28 | $87.28 | $87.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.28 / $87.28 / $87.28
| Facility | | $87.28 | $87.28 | $87.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.28 / $87.28 / $87.28
| Professional | | $87.28 | $87.28 | $87.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.28 / $87.28 / $105.70
| Professional | | $87.28 | $87.28 | $105.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.49 / $202.49 / $218.20
| Facility | | $202.49 | $202.49 | $218.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.78 / $105.20 / $218.20
| Professional | | $90.78 | $105.20 | $218.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.34 / $87.28 / $126.56
| Professional | | $76.34 | $87.28 | $126.56 |