- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $312.62 / $312.62 / $312.62
| Facility | | $312.62 | $312.62 | $312.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.05 / $1.05 / $9.65
| Professional | | $1.05 | $1.05 | $9.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $49.20 / $49.20 / $49.20
| Facility | | $49.20 | $49.20 | $49.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.98 / $31.98 / $31.98
| Professional | | $31.98 | $31.98 | $31.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $62.63 / $62.63 / $100.00
| Facility | | $62.63 | $62.63 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.96 / $252.00 / $252.00
| Professional | | $24.96 | $252.00 | $252.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $60.00 / $85.00
| Professional | | $50.00 | $60.00 | $85.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.00 / $252.00 / $252.00
| Professional | | $252.00 | $252.00 | $252.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.52 / $258.52 / $258.52
| Professional | | $258.52 | $258.52 | $258.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.52 / $258.52 / $258.52
| Professional | | $258.52 | $258.52 | $258.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.96 / $24.96 / $24.96
| Professional | | $24.96 | $24.96 | $24.96 |