- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.50 / $826.50 / $826.50
| Professional | | $826.50 | $826.50 | $826.50 |
- 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
- $54.28 / $54.28 / $54.28
| Professional | | $54.28 | $54.28 | $54.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $826.50 / $826.50 / $1,405.05
| Facility | | $826.50 | $826.50 | $1,405.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |