- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,555.86 / $1,555.86 / $1,944.83
| Professional | | $1,555.86 | $1,555.86 | $1,944.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $614.60 / $1,400.89 / $5,261.45
| Facility | | $614.60 | $1,400.89 | $5,261.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.00 / $4,273.00 / $4,273.00
| Professional | | $740.00 | $4,273.00 | $4,273.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,124.00 / $1,124.00 / $1,124.00
| Facility | | $1,124.00 | $1,124.00 | $1,124.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.00 / $1,124.00 / $1,432.85
| Professional | | $727.00 | $1,124.00 | $1,432.85 |