- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.52 / $28.52 / $28.52
| Professional | | $28.52 | $28.52 | $28.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.43 / $1,426.43 / $1,426.43
| Professional | | $1,426.43 | $1,426.43 | $1,426.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.52 / $28.52 / $53.96
| Facility | | $28.52 | $28.52 | $53.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |