- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.57 / $107.15 / $20,131.61
| Facility | | $55.57 | $107.15 | $20,131.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.57 / $56.11 / $76.31
| Professional | | $55.57 | $56.11 | $76.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.57 / $87.72 / $171.33
| Facility | | $55.57 | $87.72 | $171.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.57 / $55.57 / $62.47
| Professional | | $55.57 | $55.57 | $62.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.42 / $55.57 / $59.91
| Facility | | $52.42 | $55.57 | $59.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.57 / $55.57 / $57.66
| Professional | | $55.57 | $55.57 | $57.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.57 / $55.57 / $66.13
| Professional | | $55.57 | $55.57 | $66.13 |