- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $125.25
| Professional | | $100.00 | $100.00 | $125.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.99 / $401.21 / $677.74
| Professional | | $268.99 | $401.21 | $677.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.07 / $638.07 / $801.00
| Professional | | $638.07 | $638.07 | $801.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $220.06 / $362.58 / $362.58
| Facility | | $220.06 | $362.58 | $362.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $653.00 / $653.00 / $653.00
| Professional | | $653.00 | $653.00 | $653.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $85.00
| Professional | | $60.00 | $60.00 | $85.00 |