- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $763.90 / $960.40 / $1,153.88
| Professional | | $763.90 | $960.40 | $1,153.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $959.76 / $1,242.04 / $1,769.12
| Professional | | $959.76 | $1,242.04 | $1,769.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.40 / $1,336.80 / $2,050.71
| Professional | | $1,155.40 | $1,336.80 | $2,050.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $763.90 / $1,053.16 / $1,153.88
| Professional | | $763.90 | $1,053.16 | $1,153.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,287.46 / $14,287.46 / $14,287.46
| Facility | | $14,287.46 | $14,287.46 | $14,287.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.95 / $1,204.72 / $1,835.43
| Professional | | $876.95 | $1,204.72 | $1,835.43 |