- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.41 / $1,560.41 / $1,560.41
| Professional | | $1,560.41 | $1,560.41 | $1,560.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $574.29 / $816.75 / $1,412.31
| Facility | | $574.29 | $816.75 | $1,412.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.00 / $700.00 / $772.33
| Professional | | $600.00 | $700.00 | $772.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.00 / $1,560.41 / $2,200.00
| Professional | | $1,128.00 | $1,560.41 | $2,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $100.00 / $100.00
| Professional | | $30.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.89 / $482.89 / $482.89
| Facility | | $482.89 | $482.89 | $482.89 |