- 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 / $57.00
| Professional | | $45.60 | $45.60 | $57.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,602.67 / $1,602.67 / $9,433.95
| Facility | | $1,602.67 | $1,602.67 | $9,433.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,282.14 / $1,602.67 / $1,602.67
| Professional | | $1,282.14 | $1,602.67 | $1,602.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.60 / $45.60 / $77.06
| Facility | | $45.60 | $45.60 | $77.06 |