- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $616.60 / $831.76
| Professional | | $512.86 | $616.60 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $562.34 / $1,445.44
| Facility | | $389.05 | $562.34 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,000.00 / $10,964.78
| Facility | | $7,413.10 | $10,000.00 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,000.00 / $10,964.78
| Professional | | $7,413.10 | $10,000.00 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.13 / $199.53 / $630.96
| Facility | | $89.13 | $199.53 | $630.96 |