- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.86 / $50.98 / $3,734.20
| Facility | | $27.86 | $50.98 | $3,734.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.86 / $28.14 / $2,112.00
| Professional | | $27.86 | $28.14 | $2,112.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.54 / $32.85 / $55.72
| Facility | | $31.54 | $32.85 | $55.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.86 / $27.86 / $28.85
| Professional | | $27.86 | $27.86 | $28.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.86 / $30.65 / $44.58
| Facility | | $27.86 | $30.65 | $44.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.86 / $29.25 / $40.40
| Professional | | $27.86 | $29.25 | $40.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.86 / $71.17 / $71.17
| Facility | | $27.86 | $71.17 | $71.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.86 / $27.86 / $39.31
| Professional | | $27.86 | $27.86 | $39.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.85 / $29.82 / $38.77
| Professional | | $28.85 | $29.82 | $38.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.86 / $29.53 / $31.01
| Professional | | $27.86 | $29.53 | $31.01 |