- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.82 / $238.82 / $257.35
| Facility | | $238.82 | $238.82 | $257.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.05 / $122.80 / $122.80
| Professional | | $107.05 | $122.80 | $122.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $99.61 / $125.03 / $326.19
| Facility | | $99.61 | $125.03 | $326.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.94 / $102.94 / $102.94
| Professional | | $102.94 | $102.94 | $102.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.94 / $102.94 / $102.94
| Facility | | $102.94 | $102.94 | $102.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.94 / $102.94 / $102.94
| Professional | | $102.94 | $102.94 | $102.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.94 / $102.94 / $124.66
| Professional | | $102.94 | $102.94 | $124.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.82 / $238.82 / $257.35
| Facility | | $238.82 | $238.82 | $257.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.05 / $122.80 / $257.35
| Professional | | $107.05 | $122.80 | $257.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.94 / $102.94 / $180.15
| Professional | | $102.94 | $102.94 | $180.15 |