- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,380.38 / $1,819.70
| Professional | | $954.99 | $1,380.38 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Professional | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $2,290.87
| Facility | | $977.24 | $977.24 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $977.24 / $2,630.27
| Professional | | $162.18 | $977.24 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.20 / $660.69 / $1,288.25
| Facility | | $91.20 | $660.69 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $933.25 / $1,513.56
| Professional | | $645.65 | $933.25 | $1,513.56 |