- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.95 / $118.64 / $3,140.00
| Facility | | $74.95 | $118.64 | $3,140.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.92 / $87.42 / $119.04
| Professional | | $64.92 | $87.42 | $119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.34 / $118.35 / $182.90
| Professional | | $96.34 | $118.35 | $182.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,364.74 / $3,364.74 / $3,364.74
| Facility | | $3,364.74 | $3,364.74 | $3,364.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.10 / $84.10 / $84.10
| Professional | | $84.10 | $84.10 | $84.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.53 / $167.76 / $275.08
| Professional | | $108.53 | $167.76 | $275.08 |