- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.85 / $37.61 / $14,146.83
| Facility | | $27.85 | $37.61 | $14,146.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.85 / $27.86 / $33.43
| Professional | | $27.85 | $27.86 | $33.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.85 / $28.85 / $28.85
| Professional | | $28.85 | $28.85 | $28.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,177.97 / $1,429.52 / $1,923.16
| Facility | | $1,177.97 | $1,429.52 | $1,923.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.86 / $27.86 / $27.86
| Professional | | $27.86 | $27.86 | $27.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.86 / $27.86 / $27.86
| Facility | | $27.86 | $27.86 | $27.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.86 / $27.86 / $27.86
| Professional | | $27.86 | $27.86 | $27.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.85 / $27.86 / $30.37
| Professional | | $22.85 | $27.86 | $30.37 |