- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.96 / $1,283.84 / $4,788.87
| Professional | | $974.96 | $1,283.84 | $4,788.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $723.86 / $979.21 / $1,664.11
| Facility | | $723.86 | $979.21 | $1,664.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.60 / $1,379.13 / $1,983.47
| Professional | | $879.60 | $1,379.13 | $1,983.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,147.61 / $1,147.61 / $14,287.46
| Facility | | $1,147.61 | $1,147.61 | $14,287.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.27 / $1,508.59 / $1,714.68
| Professional | | $1,241.27 | $1,508.59 | $1,714.68 |