- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $4,570.88 / $18,197.01
| Facility | | $30.20 | $4,570.88 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $8,317.64
| Professional | | $30.20 | $30.20 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.84 / $29.51 / $29.51
| Professional | | $28.84 | $29.51 | $29.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Facility | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Facility | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.51 / $37.15 / $42.66
| Facility | | $29.51 | $37.15 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $42.66 / $87.10
| Professional | | $30.20 | $42.66 | $87.10 |