- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.10 / $211.10 / $211.10
| Facility | | $211.10 | $211.10 | $211.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.59 / $275.63 / $598.50
| Professional | | $151.59 | $275.63 | $598.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.97 / $1.00 / $1.00
| Facility | | $0.97 | $1.00 | $1.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.58 / $280.86 / $1,895.32
| Facility | | $238.58 | $280.86 | $1,895.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.13 / $50.42 / $286.20
| Professional | | $29.13 | $50.42 | $286.20 |