- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $68.81 / $122.48 / $3,977.38
| Facility | | $68.81 | $122.48 | $3,977.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.76 / $68.81 / $68.81
| Professional | | $64.76 | $68.81 | $68.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.63 / $26.64 / $40.03
| Professional | | $13.63 | $26.64 | $40.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $68.81 / $68.81 / $68.81
| Facility | | $68.81 | $68.81 | $68.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.81 / $68.81 / $68.81
| Professional | | $68.81 | $68.81 | $68.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67.19 / $68.81 / $116.29
| Facility | | $67.19 | $68.81 | $116.29 |