- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.43 / $47.81 / $2,311.40
| Facility | | $20.43 | $47.81 | $2,311.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.43 / $20.43 / $20.43
| Professional | | $20.43 | $20.43 | $20.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.43 / $20.43 / $20.43
| Facility | | $20.43 | $20.43 | $20.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.43 / $20.43 / $20.43
| Professional | | $20.43 | $20.43 | $20.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.31 / $49.64 / $2,311.40
| Facility | | $24.31 | $49.64 | $2,311.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.22 / $20.43 / $20.43
| Professional | | $19.22 | $20.43 | $20.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.43 / $20.43 / $20.43
| Facility | | $20.43 | $20.43 | $20.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.43 / $20.43 / $20.43
| Professional | | $20.43 | $20.43 | $20.43 |