- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.43 / $197.04 / $496.00
| Professional | | $50.43 | $197.04 | $496.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.25 / $56.25 / $143.25
| Professional | | $56.25 | $56.25 | $143.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $2,500.00 / $3,250.00
| Professional | | $2,500.00 | $2,500.00 | $3,250.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $228.57 / $228.57 / $228.57
| Facility | | $228.57 | $228.57 | $228.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.89 / $99.89 / $228.57
| Professional | | $99.89 | $99.89 | $228.57 |