- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,047.13 / $2,691.53
| Professional | | $954.99 | $1,047.13 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,019.95 / $3,630.78
| Professional | | $2,041.74 | $3,019.95 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,819.70 / $2,454.71
| Professional | | $1,348.96 | $1,819.70 | $2,454.71 |
- 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
- $1,122.02 / $2,089.30 / $3,630.78
| Professional | | $1,122.02 | $2,089.30 | $3,630.78 |