- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $446.68
| Professional | | $371.54 | $371.54 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Facility | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $12,022.64
| Professional | | $10,000.00 | $10,000.00 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $416.87 / $776.25
| Facility | | $371.54 | $416.87 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |