- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.36 / $22.36 / $22.36
| Facility | | $22.36 | $22.36 | $22.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.74 / $299.74 / $803.30
| Professional | | $299.74 | $299.74 | $803.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.64 / $115.16 / $207.28
| Professional | | $103.64 | $115.16 | $207.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.26 / $1,267.53 / $1,518.64
| Professional | | $1,199.26 | $1,267.53 | $1,518.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.00 / $1,608.00 / $1,608.00
| Professional | | $658.00 | $1,608.00 | $1,608.00 |