- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.03 / $105.04 / $116.24
| Professional | | $95.03 | $105.04 | $116.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.70 / $76.70 / $76.70
| Professional | | $76.70 | $76.70 | $76.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $76.48 / $105.04 / $126.05
| Facility | | $76.48 | $105.04 | $126.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Professional | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $76.48 / $105.04 / $126.05
| Facility | | $76.48 | $105.04 | $126.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.70 / $112.74 / $10,000.00
| Professional | | $76.70 | $112.74 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.96 / $216.13 / $239.73
| Professional | | $89.96 | $216.13 | $239.73 |