- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.06 / $146.06 / $146.06
| Facility | | $146.06 | $146.06 | $146.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.22 / $18.07 / $146.06
| Professional | | $14.22 | $18.07 | $146.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.69 / $48.34 / $62.50
| Professional | | $28.69 | $48.34 | $62.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.57 / $23.00 / $36.00
| Professional | | $19.57 | $23.00 | $36.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.03 / $130.03 / $130.03
| Professional | | $130.03 | $130.03 | $130.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.82 / $118.23 / $317.30
| Professional | | $23.82 | $118.23 | $317.30 |