- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.61 / $119.61 / $341.53
| Facility | | $119.61 | $119.61 | $341.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.80 / $119.61 / $119.61
| Professional | | $108.80 | $119.61 | $119.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.85 / $196.44 / $351.55
| Facility | | $125.85 | $196.44 | $351.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.67 / $106.67 / $106.67
| Professional | | $106.67 | $106.67 | $106.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.35 / $131.35 / $131.35
| Facility | | $131.35 | $131.35 | $131.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.35 / $131.35 / $131.35
| Professional | | $131.35 | $131.35 | $131.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.67 / $31.67 / $31.67
| Facility | | $31.67 | $31.67 | $31.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.67 / $35.19 / $35.19
| Professional | | $31.67 | $35.19 | $35.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.28 / $117.28 / $129.47
| Professional | | $117.28 | $117.28 | $129.47 |