- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $410.33 / $410.33 / $410.33
| Facility | | $410.33 | $410.33 | $410.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.33 / $429.48 / $441.16
| Professional | | $410.33 | $429.48 | $441.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.76 / $88.76 / $88.76
| Professional | | $88.76 | $88.76 | $88.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $410.33 / $429.48 / $549.73
| Facility | | $410.33 | $429.48 | $549.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $55.00 / $3,900.00
| Professional | | $30.00 | $55.00 | $3,900.00 |