- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.60 / $118.61 / $939.77
| Facility | | $118.60 | $118.61 | $939.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.61 / $118.61 / $118.61
| Professional | | $118.61 | $118.61 | $118.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.01 / $8.01 / $8.01
| Professional | | $8.01 | $8.01 | $8.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.23 / $14.23 / $14.23
| Professional | | $14.23 | $14.23 | $14.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.61 / $136.40 / $287.04
| Facility | | $118.61 | $136.40 | $287.04 |