- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.24 / $132.55 / $278.99
| Facility | | $126.24 | $132.55 | $278.99 |
- 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
- $101.41 / $118.98 / $144.61
| Facility | | $101.41 | $118.98 | $144.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.61 / $144.61 / $147.50
| Professional | | $144.61 | $144.61 | $147.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.24 / $120.24 / $127.45
| Facility | | $120.24 | $120.24 | $127.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $127.45
| Professional | | $127.45 | $127.45 | $127.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $215.54
| Professional | | $127.45 | $127.45 | $215.54 |