- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $284.66 / $284.66 / $306.75
| Facility | | $284.66 | $284.66 | $306.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.30 / $104.30 / $104.30
| Professional | | $104.30 | $104.30 | $104.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.03 / $0.03 / $0.03
| Facility | | $0.03 | $0.03 | $0.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.39 / $108.39 / $108.39
| Professional | | $108.39 | $108.39 | $108.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.39 / $108.39 / $108.39
| Facility | | $108.39 | $108.39 | $108.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.39 / $108.39 / $108.39
| Professional | | $108.39 | $108.39 | $108.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.39 / $108.39 / $131.26
| Professional | | $108.39 | $108.39 | $131.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $284.66 / $284.66 / $306.75
| Facility | | $284.66 | $284.66 | $306.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.30 / $104.30 / $306.75
| Professional | | $104.30 | $104.30 | $306.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.30 / $122.70 / $177.92
| Professional | | $104.30 | $122.70 | $177.92 |