- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $158.49 / $190.55
| Professional | | $102.33 | $158.49 | $190.55 |
- 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
- $91.20 / $91.20 / $91.20
| Professional | | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,905.46 / $1,905.46
| Professional | | $1,230.27 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $87.10 / $109.65
| Professional | | $63.10 | $87.10 | $109.65 |