- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.00 / $262.50 / $1,829.27
| Professional | | $1.00 | $262.50 | $1,829.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $228.57 / $228.57 / $228.57
| Facility | | $228.57 | $228.57 | $228.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.89 / $99.89 / $228.57
| Professional | | $99.89 | $99.89 | $228.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.40 / $143.40 / $200.88
| Facility | | $143.40 | $143.40 | $200.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Professional | | $50.00 | $50.00 | $50.00 |