- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $32.36
| Facility | | $32.36 | $32.36 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $173.78 / $371.54
| Professional | | $32.36 | $173.78 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Professional | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $186.21 / $263.03
| Professional | | $114.82 | $186.21 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $154.88 / $223.87
| Professional | | $89.13 | $154.88 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $204.17 / $204.17
| Professional | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Professional | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $204.17 / $204.17
| Professional | | $125.89 | $204.17 | $204.17 |