- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.87 / $7,163.10 / $7,163.10
| Facility | | $53.87 | $7,163.10 | $7,163.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.87 / $53.87 / $53.87
| Professional | | $53.87 | $53.87 | $53.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.60 / $22.60 / $22.60
| Professional | | $22.60 | $22.60 | $22.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.87 / $53.87 / $53.87
| Facility | | $53.87 | $53.87 | $53.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.67 / $16.67 / $16.67
| Professional | | $16.67 | $16.67 | $16.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.07 / $52.82 / $85.61
| Professional | | $48.07 | $52.82 | $85.61 |