- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.58 / $10.58 / $10.58
| Facility | | $10.58 | $10.58 | $10.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.58 / $20.00 / $37.72
| Professional | | $10.58 | $20.00 | $37.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.22 / $192.15 / $471.70
| Facility | | $132.22 | $192.15 | $471.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.44 / $255.54 / $406.00
| Professional | | $204.44 | $255.54 | $406.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $678.01 / $678.01 / $678.01
| Facility | | $678.01 | $678.01 | $678.01 |