- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.41 / $119.41 / $29,630.73
| Facility | | $119.41 | $119.41 | $29,630.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.74 / $36.74 / $38.21
| Professional | | $36.74 | $36.74 | $38.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.82 / $36.65 / $38.74
| Facility | | $35.82 | $36.65 | $38.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.74 / $36.74 / $36.74
| Professional | | $36.74 | $36.74 | $36.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.74 / $36.74 / $36.74
| Facility | | $36.74 | $36.74 | $36.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.74 / $36.74 / $36.74
| Professional | | $36.74 | $36.74 | $36.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.74 / $36.74 / $40.90
| Professional | | $36.74 | $36.74 | $40.90 |