- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.63 / $42.30 / $6,110.33
| Facility | | $23.63 | $42.30 | $6,110.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $23.65 / $28.59
| Professional | | $23.65 | $23.65 | $28.59 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $75.00 / $118.25 / $118.25
| Facility | | $75.00 | $118.25 | $118.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.13 / $23.13 / $23.13
| Facility | | $23.13 | $23.13 | $23.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $23.65 / $23.66
| Professional | | $23.65 | $23.65 | $23.66 |