- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.92 / $48.98 / $60.26
| Professional | | $26.92 | $48.98 | $60.26 |
- 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
- $28.84 / $28.84 / $28.84
| Professional | | $28.84 | $28.84 | $28.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $302.00 / $302.00
| Facility | | $302.00 | $302.00 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $512.86 / $512.86
| Professional | | $354.81 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.95 / $26.92 / $34.67
| Professional | | $19.95 | $26.92 | $34.67 |