- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.46 / $21.46 / $11,577.39
| Facility | | $21.46 | $21.46 | $11,577.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.46 / $21.46 / $21.46
| Professional | | $21.46 | $21.46 | $21.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.06 / $24.10 / $27.34
| Facility | | $21.06 | $24.10 | $27.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.50 / $18.50 / $18.50
| Professional | | $18.50 | $18.50 | $18.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.40 / $32.34 / $43.67
| Facility | | $24.40 | $32.34 | $43.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.50 / $18.50 / $20.59
| Professional | | $18.50 | $18.50 | $20.59 |