- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.73 / $44.54 / $44.54
| Facility | | $28.73 | $44.54 | $44.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.73 / $44.54 / $47.89
| Professional | | $28.73 | $44.54 | $47.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.00 / $79.00 / $185.65
| Professional | | $79.00 | $79.00 | $185.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.80 / $5,062.89 / $5,062.89
| Facility | | $104.80 | $5,062.89 | $5,062.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.42 / $352.42 / $518.48
| Professional | | $352.42 | $352.42 | $518.48 |