- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $1,348.96 / $2,454.71
| Facility | | $954.99 | $1,348.96 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $851.14 / $1,174.90
| Professional | | $724.44 | $851.14 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,318.26 / $1,621.81
| Professional | | $891.25 | $1,318.26 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,071.52 / $2,570.40
| Facility | | $371.54 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,000.00 / $1,548.82
| Professional | | $707.95 | $1,000.00 | $1,548.82 |