- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.20 / $100.20 / $100.20
| Facility | | $100.20 | $100.20 | $100.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.87 / $100.20 / $108.29
| Professional | | $85.87 | $100.20 | $108.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.77 / $206.16 / $235.87
| Facility | | $159.77 | $206.16 | $235.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.27 / $109.27 / $115.06
| Professional | | $109.27 | $109.27 | $115.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.67 / $112.67 / $112.67
| Facility | | $112.67 | $112.67 | $112.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.25 / $82.25 / $112.67
| Professional | | $82.25 | $82.25 | $112.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.00 / $134.00 / $134.00
| Facility | | $134.00 | $134.00 | $134.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.25 / $134.00 / $181.53
| Professional | | $128.25 | $134.00 | $181.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.29 / $120.29 / $120.29
| Facility | | $120.29 | $120.29 | $120.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.25 / $120.25 / $120.25
| Professional | | $120.25 | $120.25 | $120.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.48 / $102.85 / $192.31
| Professional | | $78.48 | $102.85 | $192.31 |