- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.61 / $1,263.61 / $1,579.52
| Professional | | $1,263.61 | $1,263.61 | $1,579.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $826.17 / $1,230.41 / $5,563.56
| Facility | | $826.17 | $1,230.41 | $5,563.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.00 / $4,522.00 / $4,522.00
| Professional | | $818.00 | $4,522.00 | $4,522.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,005.00 / $1,005.00 / $1,005.00
| Facility | | $1,005.00 | $1,005.00 | $1,005.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.00 / $1,145.84 / $1,174.84
| Professional | | $818.00 | $1,145.84 | $1,174.84 |