- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.55 / $5,176.82 / $5,176.82
| Professional | | $1,492.55 | $5,176.82 | $5,176.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.50 / $1,883.96 / $1,883.96
| Facility | | $870.50 | $1,883.96 | $1,883.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.50 / $1,532.06 / $1,883.96
| Professional | | $870.50 | $1,532.06 | $1,883.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $750.25 / $1,794.25 / $1,883.96
| Facility | | $750.25 | $1,794.25 | $1,883.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.50 / $1,413.99 / $1,885.32
| Professional | | $870.50 | $1,413.99 | $1,885.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.77 / $671.35 / $1,064.76
| Professional | | $606.77 | $671.35 | $1,064.76 |