- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.05 / $47.60 / $62.18
| Facility | | $25.05 | $47.60 | $62.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.00 / $27.26 / $2,265.94
| Professional | | $27.00 | $27.26 | $2,265.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.00 / $28.35 / $33.82
| Facility | | $27.00 | $28.35 | $33.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.05 / $25.05 / $27.00
| Professional | | $25.05 | $25.05 | $27.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.26 / $27.00 / $27.00
| Facility | | $26.26 | $27.00 | $27.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.00 / $27.00 / $27.00
| Professional | | $27.00 | $27.00 | $27.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.00 / $28.35 / $90.41
| Professional | | $27.00 | $28.35 | $90.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.04 / $30.04 / $30.04
| Facility | | $30.04 | $30.04 | $30.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.00 / $27.00 / $27.00
| Professional | | $27.00 | $27.00 | $27.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.00 / $27.00 / $27.00
| Professional | | $27.00 | $27.00 | $27.00 |