- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.68 / $1,450.68 / $1,813.36
| Professional | | $1,450.68 | $1,450.68 | $1,813.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,033.22 / $1,368.38 / $2,812.02
| Facility | | $1,033.22 | $1,368.38 | $2,812.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.00 / $1,388.07 / $4,309.00
| Professional | | $1,272.00 | $1,388.07 | $4,309.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $811.95 / $1,052.29 / $1,272.00
| Facility | | $811.95 | $1,052.29 | $1,272.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.20 / $1,272.00 / $1,480.07
| Professional | | $737.20 | $1,272.00 | $1,480.07 |