- 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
- $446.68 / $537.03 / $724.44
| Professional | | $446.68 | $537.03 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $954.99 / $2,238.72
| Facility | | $354.81 | $954.99 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $309.03
| Facility | | $186.21 | $186.21 | $309.03 |
- 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
- $323.59 / $870.96 / $2,454.71
| Facility | | $323.59 | $870.96 | $2,454.71 |