- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $69.18 / $69.18 / $69.18
| Facility | | $69.18 | $69.18 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $87.10 / $218.78
| Professional | | $69.18 | $87.10 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $173.78 / $1,023.29
| Facility | | $151.36 | $173.78 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $125.89 / $165.96
| Professional | | $75.86 | $125.89 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.33 / $93.33 / $281.84
| Facility | | $93.33 | $93.33 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $138.04 / $138.04
| Professional | | $93.33 | $138.04 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.33 / $112.20 / $112.20
| Facility | | $93.33 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $83.18 / $112.20
| Professional | | $83.18 | $83.18 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $4,897.79 / $9,772.37
| Facility | | $83.18 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $213.80
| Professional | | $141.25 | $141.25 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $91.20 / $91.20
| Professional | | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $173.78 / $1,023.29
| Facility | | $151.36 | $173.78 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $125.89 / $213.80
| Professional | | $77.62 | $125.89 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.13 / $120.23 / $218.78
| Facility | | $0.13 | $120.23 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $114.82 / $141.25
| Professional | | $69.18 | $114.82 | $141.25 |