- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $707.95 / $933.25
| Professional | | $575.44 | $707.95 | $933.25 |
- 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
- $204.17 / $204.17 / $251.19
| Facility | | $204.17 | $204.17 | $251.19 |
- 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 |