- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.65 / $406.35 / $514.02
| Professional | | $400.65 | $406.35 | $514.02 |
- 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
- $835.00 / $1,002.00 / $1,613.00
| Professional | | $835.00 | $1,002.00 | $1,613.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.69 / $821.32 / $1,044.58
| Professional | | $505.69 | $821.32 | $1,044.58 |
- 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
- $436.62 / $807.98 / $1,325.99
| Professional | | $436.62 | $807.98 | $1,325.99 |