- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $445.48 / $455.53 / $604.16
| Professional | | $445.48 | $455.53 | $604.16 |
- 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
- $925.00 / $1,110.00 / $1,787.00
| Professional | | $925.00 | $1,110.00 | $1,787.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.71 / $928.80 / $1,167.72
| Professional | | $580.71 | $928.80 | $1,167.72 |
- 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
- $661.50 / $948.23 / $1,556.10
| Professional | | $661.50 | $948.23 | $1,556.10 |