- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $350.00 / $350.00
| Professional | | $350.00 | $350.00 | $350.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.00 / $28.00 / $34.29
| Facility | | $28.00 | $28.00 | $34.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.25 / $24.50 / $31.50
| Professional | | $19.25 | $24.50 | $31.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.24 / $111.24 / $111.24
| Professional | | $111.24 | $111.24 | $111.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Professional | | $50.00 | $50.00 | $50.00 |