- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.45 / $250.33 / $263.83
| Facility | | $127.45 | $250.33 | $263.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $152.75
| Professional | | $127.45 | $127.45 | $152.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.27 / $219.21 / $407.84
| Facility | | $138.27 | $219.21 | $407.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $127.45
| Professional | | $127.45 | $127.45 | $127.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.24 / $120.24 / $202.60
| Facility | | $120.24 | $120.24 | $202.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $127.45
| Professional | | $127.45 | $127.45 | $127.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.24 / $170.42 / $211.43
| Facility | | $126.24 | $170.42 | $211.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.59 / $140.19 / $209.02
| Professional | | $95.59 | $140.19 | $209.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $127.45
| Professional | | $127.45 | $127.45 | $127.45 |