- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.36 / $124.80 / $1,477.79
| Facility | | $80.36 | $124.80 | $1,477.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.80 / $114.73 / $114.73
| Professional | | $69.80 | $114.73 | $114.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.75 / $71.75 / $118.39
| Professional | | $71.75 | $71.75 | $118.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.62 / $1.62 / $1.62
| Professional | | $1.62 | $1.62 | $1.62 |