- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $141.25 / $158.49
| Professional | | $89.13 | $141.25 | $158.49 |
- 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
- $81.28 / $81.28 / $81.28
| Professional | | $81.28 | $81.28 | $81.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,698.24 / $1,698.24
| Professional | | $1,071.52 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $79.43 / $93.33
| Professional | | $56.23 | $79.43 | $93.33 |