- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $128.82 / $275.42
| Facility | | $128.82 | $128.82 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $131.83 / $138.04
| Professional | | $128.82 | $131.83 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.03 / $162.18 / $162.18
| Facility | | $0.03 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $138.04 / $138.04
| Professional | | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.33 / $93.33 / $147.91
| Facility | | $93.33 | $93.33 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $91.20 / $93.33
| Professional | | $79.43 | $91.20 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $169.82 / $169.82
| Facility | | $138.04 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $512.86 / $512.86
| Professional | | $138.04 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $331.13
| Professional | | $331.13 | $331.13 | $331.13 |