- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.38 / $100.38 / $175.67
| Facility | | $100.38 | $100.38 | $175.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.75 / $100.38 / $102.80
| Professional | | $96.75 | $100.38 | $102.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.86 / $117.51 / $127.49
| Professional | | $110.86 | $117.51 | $127.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.80 / $102.80 / $102.80
| Facility | | $102.80 | $102.80 | $102.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.80 / $102.80 / $102.80
| Professional | | $102.80 | $102.80 | $102.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.94 / $241.88 / $453.53
| Facility | | $120.94 | $241.88 | $453.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.57 / $459.57 / $544.23
| Professional | | $459.57 | $459.57 | $544.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.78 / $100.78 / $100.78
| Professional | | $100.78 | $100.78 | $100.78 |