- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.74 / $136.74 / $147.35
| Facility | | $136.74 | $136.74 | $147.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.33 / $50.10 / $58.94
| Professional | | $48.33 | $50.10 | $58.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46.31 / $57.89 / $165.01
| Facility | | $46.31 | $57.89 | $165.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.07 / $52.07 / $52.07
| Professional | | $52.07 | $52.07 | $52.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.07 / $52.07 / $70.00
| Facility | | $52.07 | $52.07 | $70.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.07 / $52.07 / $52.07
| Professional | | $52.07 | $52.07 | $52.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.07 / $52.07 / $52.07
| Professional | | $52.07 | $52.07 | $52.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.74 / $136.74 / $147.35
| Facility | | $136.74 | $136.74 | $147.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.33 / $50.10 / $58.94
| Professional | | $48.33 | $50.10 | $58.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.07 / $58.94 / $85.46
| Professional | | $52.07 | $58.94 | $85.46 |