- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.61 / $80.61 / $1,829.01
| Facility | | $80.61 | $80.61 | $1,829.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.79 / $60.13 / $80.61
| Professional | | $57.79 | $60.13 | $80.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.57 / $166.80 / $182.57
| Professional | | $141.57 | $166.80 | $182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.45 / $101.25 / $126.56
| Professional | | $67.45 | $101.25 | $126.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.61 / $80.61 / $149.13
| Facility | | $80.61 | $80.61 | $149.13 |