- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.60 / $15,196.63 / $37,680.68
| Facility | | $180.60 | $15,196.63 | $37,680.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.57 / $55.57 / $57.79
| Professional | | $55.57 | $55.57 | $57.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.67 / $54.67 / $59.91
| Facility | | $54.67 | $54.67 | $59.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.57 / $55.57 / $55.57
| Professional | | $55.57 | $55.57 | $55.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.57 / $55.57 / $55.57
| Facility | | $55.57 | $55.57 | $55.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.57 / $55.57 / $55.57
| Professional | | $55.57 | $55.57 | $55.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.57 / $55.57 / $61.86
| Professional | | $55.57 | $55.57 | $61.86 |