- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.88 / $196.83 / $196.83
| Facility | | $177.88 | $196.83 | $196.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.24 / $180.89 / $223.71
| Professional | | $160.24 | $180.89 | $223.71 |
- 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
- $161.71 / $161.71 / $161.71
| Professional | | $161.71 | $161.71 | $161.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.05 / $45.05 / $258.38
| Professional | | $45.05 | $45.05 | $258.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.34 / $138.34 / $219.77
| Facility | | $138.34 | $138.34 | $219.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.34 / $138.34 / $154.57
| Professional | | $138.34 | $138.34 | $154.57 |
- 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
- $161.71 / $161.71 / $161.71
| Professional | | $161.71 | $161.71 | $161.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.21 / $149.34 / $149.34
| Professional | | $10.21 | $149.34 | $149.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.71 / $161.71 / $161.71
| Professional | | $161.71 | $161.71 | $161.71 |