- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.89 / $354.09 / $485.63
| Professional | | $276.89 | $354.09 | $485.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $800.00 / $3,174.57 / $4,232.76
| Facility | | $800.00 | $3,174.57 | $4,232.76 |
- 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
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.40 / $1,463.63 / $1,463.63
| Facility | | $520.40 | $1,463.63 | $1,463.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.63 / $1,463.63 / $1,463.63
| Professional | | $1,463.63 | $1,463.63 | $1,463.63 |