- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.50 / $37.50 / $41.50
| Professional | | $37.50 | $37.50 | $41.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.06 / $519.04 / $2,126.00
| Facility | | $246.06 | $519.04 | $2,126.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,335.23 / $3,335.23 / $3,335.23
| Professional | | $3,335.23 | $3,335.23 | $3,335.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,204.00 / $1,640.00 / $2,126.00
| Facility | | $1,204.00 | $1,640.00 | $2,126.00 |