- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.60 / $280.58 / $357.21
| Facility | | $141.60 | $280.58 | $357.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $149.46 / $194.45
| Professional | | $141.60 | $149.46 | $194.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.62 / $243.55 / $453.12
| Facility | | $153.62 | $243.55 | $453.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $141.60
| Professional | | $141.60 | $141.60 | $141.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.59 / $133.59 / $188.85
| Facility | | $133.59 | $133.59 | $188.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $141.60
| Professional | | $141.60 | $141.60 | $141.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.59 / $150.10 / $234.89
| Facility | | $124.59 | $150.10 | $234.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.20 / $155.76 / $232.22
| Professional | | $106.20 | $155.76 | $232.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $141.60
| Professional | | $141.60 | $141.60 | $141.60 |