- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.54 / $906.54 / $906.54
| Professional | | $906.54 | $906.54 | $906.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $10.00 / $15.98
| Professional | | $10.00 | $10.00 | $15.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.39 / $510.39 / $611.51
| Professional | | $510.39 | $510.39 | $611.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $906.54 / $906.54 / $1,380.66
| Facility | | $906.54 | $906.54 | $1,380.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $9,929.00 / $10,945.00
| Facility | | $100.00 | $9,929.00 | $10,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $9,929.00 / $10,945.00
| Professional | | $100.00 | $9,929.00 | $10,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.63 / $224.52 / $336.05
| Professional | | $201.63 | $224.52 | $336.05 |