- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.00 / $107.00 / $227.38
| Facility | | $107.00 | $107.00 | $227.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.67 / $86.67 / $86.67
| Professional | | $86.67 | $86.67 | $86.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.80 / $47.08 / $371.66
| Professional | | $42.80 | $47.08 | $371.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.00 / $107.00 / $108.07
| Professional | | $107.00 | $107.00 | $108.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.00 / $107.00 / $173.34
| Facility | | $107.00 | $107.00 | $173.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.67 / $86.67 / $107.00
| Professional | | $86.67 | $86.67 | $107.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.20 / $64.20 / $160.50
| Professional | | $64.20 | $64.20 | $160.50 |