- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.65 / $434.88 / $879.52
| Professional | | $350.65 | $434.88 | $879.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.40 / $1,650.40 / $1,650.40
| Facility | | $1,650.40 | $1,650.40 | $1,650.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $867.00 / $1,396.00 / $2,950.00
| Professional | | $867.00 | $1,396.00 | $2,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $484.96 / $818.57 / $1,848.24
| Professional | | $484.96 | $818.57 | $1,848.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.18 / $1,237.59 / $2,021.48
| Professional | | $873.18 | $1,237.59 | $2,021.48 |