- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $81.28 / $100.00
| Professional | | $43.65 | $81.28 | $100.00 |
- 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
- $46.77 / $46.77 / $46.77
| Professional | | $46.77 | $46.77 | $46.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $977.24 / $977.24
| Professional | | $645.65 | $977.24 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $43.65 / $52.48
| Professional | | $32.36 | $43.65 | $52.48 |