- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,461.60 / $1,461.60 / $2,084.42
| Facility | | $1,461.60 | $1,461.60 | $2,084.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $696.00 / $1,125.20 / $1,461.60
| Professional | | $696.00 | $1,125.20 | $1,461.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $754.00 / $874.64 / $1,734.20
| Facility | | $754.00 | $874.64 | $1,734.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.36 / $561.38 / $1,731.53
| Professional | | $528.36 | $561.38 | $1,731.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.20 / $696.00 / $1,160.00
| Professional | | $487.20 | $696.00 | $1,160.00 |