- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,096.48 / $2,344.23
| Professional | | $954.99 | $1,096.48 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,019.95 / $3,019.95
| Professional | | $2,691.53 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,584.89 / $2,630.27
| Professional | | $1,479.11 | $1,584.89 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,090.30
| Facility | | $1,288.25 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,905.46 / $3,890.45
| Professional | | $1,258.93 | $1,905.46 | $3,890.45 |