- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,620.00 / $1,620.00 / $1,620.00
| Professional | | $1,620.00 | $1,620.00 | $1,620.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.00 / $119.00 / $403.00
| Professional | | $77.00 | $119.00 | $403.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.48 / $77.76 / $244.11
| Professional | | $41.48 | $77.76 | $244.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.55 / $287.11 / $584.77
| Professional | | $143.55 | $287.11 | $584.77 |