- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.78 / $27.78 / $3,643.20
| Facility | | $27.78 | $27.78 | $3,643.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.78 / $27.78 / $27.78
| Professional | | $27.78 | $27.78 | $27.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.31 / $56.40 / $56.40
| Facility | | $54.31 | $56.40 | $56.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.45 / $44.45 / $44.45
| Facility | | $44.45 | $44.45 | $44.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.02 / $36.96 / $36.96
| Professional | | $20.02 | $36.96 | $36.96 |