- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,583.50 / $2,583.50 / $3,229.37
| Professional | | $2,583.50 | $2,583.50 | $3,229.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $2,077.00 / $4,664.43
| Facility | | $55.00 | $2,077.00 | $4,664.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,077.00 / $2,610.00 / $13,636.00
| Professional | | $2,077.00 | $2,610.00 | $13,636.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,495.76 / $1,938.51 / $2,077.00
| Facility | | $1,495.76 | $1,938.51 | $2,077.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,358.22 / $2,320.00 / $2,922.09
| Professional | | $1,358.22 | $2,320.00 | $2,922.09 |