- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Facility | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Professional | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $218.78 / $363.08
| Professional | | $218.78 | $218.78 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $114.82
| Professional | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $190.55 / $190.55
| Facility | | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Professional | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $316.23
| Professional | | $288.40 | $288.40 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $67.61
| Facility | | $39.81 | $39.81 | $67.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $7,413.10 / $10,964.78
| Facility | | $512.86 | $7,413.10 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $7,413.10 / $10,964.78
| Professional | | $512.86 | $7,413.10 | $10,964.78 |