- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.86 / $182.86 / $182.86
| Facility | | $182.86 | $182.86 | $182.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.12 / $182.86 / $182.86
| Professional | | $96.12 | $182.86 | $182.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.04 / $246.47 / $447.96
| Facility | | $158.04 | $246.47 | $447.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.53 / $47.53 / $48.48
| Professional | | $47.53 | $47.53 | $48.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.71 / $16.72 / $40.22
| Facility | | $10.71 | $16.72 | $40.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.25 / $5.62 / $6.67
| Professional | | $5.25 | $5.62 | $6.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.60 / $13.76 / $31.68
| Facility | | $8.60 | $13.76 | $31.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.25 / $5.25 / $5.60
| Professional | | $5.25 | $5.25 | $5.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.26 / $182.86 / $309.02
| Facility | | $174.26 | $182.86 | $309.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.37 / $47.32 / $158.31
| Professional | | $11.37 | $47.32 | $158.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.40 / $111.40 / $111.40
| Professional | | $111.40 | $111.40 | $111.40 |