- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.60 / $45.60 / $45.60
| Facility | | $45.60 | $45.60 | $45.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.60 / $45.60 / $60.00
| Professional | | $45.60 | $45.60 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,739.54 / $1,897.92 / $2,013.11
| Facility | | $1,739.54 | $1,897.92 | $2,013.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,883.84 / $1,883.84 / $1,883.84
| Professional | | $1,883.84 | $1,883.84 | $1,883.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.60 / $45.60 / $60.00
| Facility | | $45.60 | $45.60 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.00 / $57.00 / $57.00
| Professional | | $57.00 | $57.00 | $57.00 |