- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.05 / $112.05 / $2,140.73
| Facility | | $112.05 | $112.05 | $2,140.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.46 / $112.05 / $112.05
| Professional | | $105.46 | $112.05 | $112.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $68.94
| Professional | | $0.02 | $0.02 | $68.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.05 / $112.05 / $112.05
| Facility | | $112.05 | $112.05 | $112.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.05 / $112.05 / $112.05
| Professional | | $112.05 | $112.05 | $112.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.89 / $112.05 / $189.36
| Facility | | $106.89 | $112.05 | $189.36 |