- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.68 / $28.52 / $28.52
| Professional | | $11.68 | $28.52 | $28.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.43 / $1,426.43 / $1,426.43
| Professional | | $1,426.43 | $1,426.43 | $1,426.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,975.05 / $1,975.05 / $1,975.05
| Professional | | $1,975.05 | $1,975.05 | $1,975.05 |