- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.02 / $37.02 / $37.02
| Facility | | $37.02 | $37.02 | $37.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.02 / $37.02 / $47.20
| Professional | | $37.02 | $37.02 | $47.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,057.16 / $2,216.51 / $3,868.86
| Facility | | $1,057.16 | $2,216.51 | $3,868.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.02 / $45.63 / $69.16
| Facility | | $37.02 | $45.63 | $69.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |