- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,403.77 / $1,403.77 / $1,403.77
| Facility | | $1,403.77 | $1,403.77 | $1,403.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.05 / $32.40 / $46.05
| Professional | | $27.05 | $32.40 | $46.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.44 / $43.33 / $56.09
| Professional | | $16.44 | $43.33 | $56.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.19 / $35.19 / $35.19
| Professional | | $35.19 | $35.19 | $35.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.44 / $65.36 / $129.50
| Professional | | $41.44 | $65.36 | $129.50 |