- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.40 / $5,065.30 / $5,065.30
| Professional | | $1,460.40 | $5,065.30 | $5,065.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $895.00 / $1,695.92 / $1,695.92
| Facility | | $895.00 | $1,695.92 | $1,695.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.00 / $1,379.13 / $1,695.92
| Professional | | $895.00 | $1,379.13 | $1,695.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $798.55 / $1,615.16 / $1,695.92
| Facility | | $798.55 | $1,615.16 | $1,695.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.00 / $1,272.85 / $1,697.15
| Professional | | $895.00 | $1,272.85 | $1,697.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.84 / $714.57 / $1,133.30
| Professional | | $645.84 | $714.57 | $1,133.30 |