- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.47 / $1,063.47 / $1,329.34
| Professional | | $1,063.47 | $1,063.47 | $1,329.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $816.49 / $1,272.20 / $1,383.46
| Facility | | $816.49 | $1,272.20 | $1,383.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $972.00 / $9,087.00 / $9,087.00
| Professional | | $972.00 | $9,087.00 | $9,087.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $909.00 / $909.00 / $909.00
| Facility | | $909.00 | $909.00 | $909.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.00 / $909.00 / $1,004.70
| Professional | | $832.00 | $909.00 | $1,004.70 |