- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $677.66 / $883.65 / $3,641.43
| Professional | | $677.66 | $883.65 | $3,641.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.80 / $896.23 / $1,285.65
| Professional | | $761.80 | $896.23 | $1,285.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.73 / $2,698.21 / $5,555.42
| Professional | | $878.73 | $2,698.21 | $5,555.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.65 / $2,555.06 / $5,041.18
| Professional | | $839.65 | $2,555.06 | $5,041.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $764.93 / $920.56 / $3,641.43
| Professional | | $764.93 | $920.56 | $3,641.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,831.32 / $11,831.32 / $11,831.32
| Facility | | $11,831.32 | $11,831.32 | $11,831.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,460.19 / $3,907.36 / $5,289.41
| Professional | | $2,460.19 | $3,907.36 | $5,289.41 |