- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.65 / $46.55 / $73.09
| Facility | | $23.65 | $46.55 | $73.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $23.65 / $23.89
| Professional | | $23.65 | $23.65 | $23.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.65 / $25.25 / $32.67
| Facility | | $23.65 | $25.25 | $32.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $23.65 / $23.65
| Professional | | $23.65 | $23.65 | $23.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.40 / $3,243.00 / $13,785.00
| Facility | | $39.40 | $3,243.00 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.60 / $23.63 / $23.63
| Professional | | $22.60 | $23.63 | $23.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $23.65 / $27.84
| Professional | | $23.65 | $23.65 | $27.84 |