- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.09 / $100.09 / $172.32
| Professional | | $100.09 | $100.09 | $172.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.31 / $113.31 / $113.31
| Facility | | $113.31 | $113.31 | $113.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.42 / $109.97 / $183.28
| Facility | | $94.42 | $109.97 | $183.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.09 / $100.09 / $183.28
| Professional | | $100.09 | $100.09 | $183.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.42 / $109.97 / $183.28
| Facility | | $94.42 | $109.97 | $183.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.09 / $100.09 / $183.28
| Professional | | $100.09 | $100.09 | $183.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.09 / $106.10 / $231.64
| Professional | | $100.09 | $106.10 | $231.64 |