- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,258.93 / $1,513.56
| Professional | | $954.99 | $1,258.93 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,995.26
| Facility | | $1,548.82 | $1,548.82 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,584.89
| Professional | | $1,122.02 | $1,122.02 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,089.30 / $2,691.53
| Professional | | $1,949.84 | $2,089.30 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,258.93 / $1,412.54
| Facility | | $1,000.00 | $1,258.93 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,584.89 / $5,623.41
| Professional | | $912.01 | $1,584.89 | $5,623.41 |