- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.36 / $98.36 / $195.74
| Facility | | $98.36 | $98.36 | $195.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.36 / $98.36 / $98.36
| Professional | | $98.36 | $98.36 | $98.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.82 / $11.82 / $11.82
| Professional | | $11.82 | $11.82 | $11.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $88.52 / $106.25 / $734.60
| Facility | | $88.52 | $106.25 | $734.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.19 / $101.19 / $101.19
| Professional | | $101.19 | $101.19 | $101.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.19 / $101.19 / $103.21
| Professional | | $101.19 | $101.19 | $103.21 |