- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.48 / $328.78 / $410.98
| Professional | | $168.48 | $328.78 | $410.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,300.00 / $1,300.00 / $1,300.00
| Facility | | $1,300.00 | $1,300.00 | $1,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.93 / $615.83 / $615.83
| Professional | | $281.93 | $615.83 | $615.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.00 / $211.00 / $211.00
| Facility | | $211.00 | $211.00 | $211.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.17 / $211.00 / $297.54
| Professional | | $122.17 | $211.00 | $297.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $102.20 / $354.50
| Professional | | $5.00 | $102.20 | $354.50 |