- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.63 / $23.65 / $23.65
| Facility | | $23.63 | $23.65 | $23.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $23.89 / $31.92
| Professional | | $23.65 | $23.89 | $31.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,177.85 / $6,283.58 / $8,453.43
| Facility | | $5,177.85 | $6,283.58 | $8,453.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.39 / $23.65 / $23.65
| Professional | | $23.39 | $23.65 | $23.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.65 / $23.65 / $23.65
| Facility | | $23.65 | $23.65 | $23.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $23.65 / $23.65
| Professional | | $23.65 | $23.65 | $23.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.54 / $23.65 / $23.65
| Professional | | $22.54 | $23.65 | $23.65 |