- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $63.28 / $63.28 / $69.29
| Facility | | $63.28 | $63.28 | $69.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.28 / $69.29 / $69.29
| Professional | | $63.28 | $69.29 | $69.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.13 / $48.49 / $63.09
| Professional | | $42.13 | $48.49 | $63.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.68 / $127.68 / $127.68
| Facility | | $127.68 | $127.68 | $127.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.92 / $104.92 / $104.92
| Professional | | $104.92 | $104.92 | $104.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $158.00
| Professional | | $64.00 | $64.00 | $158.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $63.28 / $69.29 / $92.16
| Facility | | $63.28 | $69.29 | $92.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,071.00 / $4,071.00 / $4,071.00
| Facility | | $4,071.00 | $4,071.00 | $4,071.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,071.00 / $4,071.00 / $4,071.00
| Professional | | $4,071.00 | $4,071.00 | $4,071.00 |