- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.52 / $744.83 / $1,239.98
| Professional | | $549.52 | $744.83 | $1,239.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.13 / $971.06 / $1,493.21
| Professional | | $661.13 | $971.06 | $1,493.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.09 / $997.57 / $1,638.04
| Professional | | $679.09 | $997.57 | $1,638.04 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $704.63 / $876.16 / $1,686.35
| Professional | | $704.63 | $876.16 | $1,686.35 |