- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $213.80 / $213.80
| Professional | | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.30 / $26.30 / $39.81
| Professional | | $26.30 | $26.30 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $288.40 / $407.38
| Facility | | $213.80 | $288.40 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $10,000.00 / $10,964.78
| Facility | | $100.00 | $10,000.00 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $10,000.00 / $10,964.78
| Professional | | $100.00 | $10,000.00 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.15 / $257.04 / $812.83
| Facility | | $107.15 | $257.04 | $812.83 |