- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.18 / $1,251.83 / $4,679.41
| Professional | | $953.18 | $1,251.83 | $4,679.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.07 / $1,428.07 / $1,428.07
| Professional | | $1,428.07 | $1,428.07 | $1,428.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.54 / $972.87 / $1,638.81
| Facility | | $707.54 | $972.87 | $1,638.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.22 / $1,346.77 / $1,940.93
| Professional | | $859.22 | $1,346.77 | $1,940.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.85 / $1,122.85 / $1,122.85
| Facility | | $1,122.85 | $1,122.85 | $1,122.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.95 / $1,473.45 / $1,654.40
| Professional | | $1,214.95 | $1,473.45 | $1,654.40 |