- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $177.83 / $218.78
| Professional | | $109.65 | $177.83 | $218.78 |
- 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
- $102.33 / $102.33 / $102.33
| Professional | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Facility | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,137.96 / $2,137.96
| Professional | | $1,659.59 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $95.50 / $114.82
| Professional | | $70.79 | $95.50 | $114.82 |