- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $32.36
| Facility | | $32.36 | $32.36 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $37.15 / $52.48
| Professional | | $32.36 | $37.15 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $933.25 / $1,122.02
| Facility | | $831.76 | $933.25 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $125.89 / $199.53
| Professional | | $102.33 | $125.89 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |