- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.56 / $107.56 / $107.56
| Facility | | $107.56 | $107.56 | $107.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.56 / $107.56 / $107.56
| Professional | | $107.56 | $107.56 | $107.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.06 / $208.24 / $260.30
| Professional | | $133.06 | $208.24 | $260.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.99 / $129.57 / $543.54
| Facility | | $107.99 | $129.57 | $543.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.36 / $102.99 / $171.65
| Professional | | $58.36 | $102.99 | $171.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.32 / $200.25 / $225.20
| Facility | | $137.32 | $200.25 | $225.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.32 / $200.25 / $295.29
| Professional | | $137.32 | $200.25 | $295.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.43 / $275.70 / $314.36
| Professional | | $114.43 | $275.70 | $314.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.06 / $68.66 / $137.32
| Professional | | $48.06 | $68.66 | $137.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.43 / $114.43 / $114.43
| Professional | | $114.43 | $114.43 | $114.43 |