- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $93.33 / $102.33
| Professional | | $45.71 | $93.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.98 / $48.98 / $48.98
| Professional | | $48.98 | $48.98 | $48.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $891.25 / $891.25
| Professional | | $812.83 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $51.29 / $58.88
| Professional | | $33.88 | $51.29 | $58.88 |