- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.61 / $118.61 / $152.28
| Facility | | $118.61 | $118.61 | $152.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.61 / $118.61 / $152.28
| Professional | | $118.61 | $118.61 | $152.28 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $493.00
| Professional | | $100.00 | $200.00 | $493.00 |