- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.97 / $242.97 / $261.83
| Facility | | $242.97 | $242.97 | $261.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.92 / $126.99 / $126.99
| Professional | | $108.92 | $126.99 | $126.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.35 / $127.22 / $331.89
| Facility | | $101.35 | $127.22 | $331.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $104.73
| Professional | | $104.73 | $104.73 | $104.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $104.73
| Facility | | $104.73 | $104.73 | $104.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $104.73
| Professional | | $104.73 | $104.73 | $104.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $126.83
| Professional | | $104.73 | $104.73 | $126.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.97 / $242.97 / $261.83
| Facility | | $242.97 | $242.97 | $261.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.92 / $126.99 / $261.83
| Professional | | $108.92 | $126.99 | $261.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $151.86
| Professional | | $104.73 | $104.73 | $151.86 |