- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $232.30 / $232.30 / $232.30
| Facility | | $232.30 | $232.30 | $232.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.30 / $232.30 / $283.97
| Professional | | $232.30 | $232.30 | $283.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,038.96 / $1,038.96 / $1,038.96
| Professional | | $1,038.96 | $1,038.96 | $1,038.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.57 / $61.57 / $592.28
| Professional | | $61.57 | $61.57 | $592.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.50 / $26.98 / $47.41
| Professional | | $17.50 | $26.98 | $47.41 |