- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.73 / $121.73 / $131.18
| Facility | | $121.73 | $121.73 | $131.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.47 / $54.57 / $62.97
| Professional | | $52.47 | $54.57 | $62.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46.67 / $58.33 / $166.28
| Facility | | $46.67 | $58.33 | $166.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.47 / $52.47 / $54.45
| Professional | | $52.47 | $52.47 | $54.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.28 / $52.47 / $85.00
| Facility | | $50.28 | $52.47 | $85.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.47 / $52.47 / $52.47
| Professional | | $52.47 | $52.47 | $52.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.47 / $52.47 / $52.47
| Professional | | $52.47 | $52.47 | $52.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.73 / $121.73 / $131.18
| Facility | | $121.73 | $121.73 | $131.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.47 / $55.10 / $87.43
| Professional | | $52.47 | $55.10 | $87.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.47 / $52.47 / $76.08
| Professional | | $52.47 | $52.47 | $76.08 |