- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.23 / $521.13 / $827.78
| Facility | | $21.23 | $521.13 | $827.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.23 / $21.23 / $25.73
| Professional | | $21.23 | $21.23 | $25.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.40 / $26.40 / $26.40
| Professional | | $26.40 | $26.40 | $26.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.21 / $28.21 / $28.21
| Professional | | $28.21 | $28.21 | $28.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.55 / $21.23 / $26.46
| Professional | | $19.55 | $21.23 | $26.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.23 / $21.23 / $34.40
| Professional | | $21.23 | $21.23 | $34.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.23 / $21.23 / $21.23
| Professional | | $21.23 | $21.23 | $21.23 |