- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.93 / $6,937.81 / $10,406.71
| Facility | | $58.93 | $6,937.81 | $10,406.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.93 / $58.93 / $58.93
| Professional | | $58.93 | $58.93 | $58.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.93 / $58.93 / $58.93
| Professional | | $58.93 | $58.93 | $58.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.93 / $58.93 / $58.93
| Facility | | $58.93 | $58.93 | $58.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.93 / $58.93 / $58.93
| Professional | | $58.93 | $58.93 | $58.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.98 / $55.98 / $72.45
| Professional | | $55.98 | $55.98 | $72.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.78 / $57.78 / $93.65
| Professional | | $57.78 | $57.78 | $93.65 |