- 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
- $1,086.66 / $1,468.34 / $2,812.02
| Facility | | $1,086.66 | $1,468.34 | $2,812.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.00 / $4,309.00 / $4,309.00
| Professional | | $1,272.00 | $4,309.00 | $4,309.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $811.95 / $811.95 / $1,272.00
| Facility | | $811.95 | $811.95 | $1,272.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.95 / $1,224.00 / $1,411.00
| Professional | | $811.95 | $1,224.00 | $1,411.00 |