- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.50 / $326.20 / $573.75
| Facility | | $127.50 | $326.20 | $573.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $128.72 / $128.72
| Professional | | $127.45 | $128.72 | $128.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.45 / $254.90 / $337.74
| Facility | | $127.45 | $254.90 | $337.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.33 / $127.45 / $180.97
| Professional | | $108.33 | $127.45 | $180.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $191.18
| Facility | | $127.45 | $127.45 | $191.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $159.31
| Professional | | $127.45 | $127.45 | $159.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $362.00
| Facility | | $127.45 | $127.45 | $362.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $373.78
| Professional | | $127.45 | $127.45 | $373.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $172.43
| Professional | | $127.45 | $127.45 | $172.43 |