- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $1,151.23
| Facility | | $100.00 | $100.00 | $1,151.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.52 / $100.73 / $217.46
| Professional | | $94.52 | $100.73 | $217.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.97 / $195.69 / $322.95
| Facility | | $145.97 | $195.69 | $322.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $250.00 / $846.13 / $13,785.00
| Facility | | $250.00 | $846.13 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.50 / $250.00 / $250.00
| Professional | | $212.50 | $250.00 | $250.00 |