- 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
- $660.69 / $812.83 / $1,071.52
| Professional | | $660.69 | $812.83 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $977.24 / $2,238.72
| Facility | | $562.34 | $977.24 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.82 / $169.82 / $309.03
| Facility | | $169.82 | $169.82 | $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 |