- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,096.48 / $1,258.93
| Professional | | $870.96 | $1,096.48 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,445.44
| Facility | | $1,318.26 | $1,318.26 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $1,348.96
| Professional | | $954.99 | $954.99 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,949.84 / $2,398.83
| Professional | | $1,548.82 | $1,949.84 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,202.26 / $1,445.44
| Facility | | $1,000.00 | $1,202.26 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,479.11 / $4,168.69
| Professional | | $691.83 | $1,479.11 | $4,168.69 |