- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.79 / $1,126.46 / $3,440.00
| Professional | | $750.79 | $1,126.46 | $3,440.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,150.46 / $8,150.46 / $10,123.27
| Facility | | $8,150.46 | $8,150.46 | $10,123.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $629.85 / $1,204.83 / $2,575.15
| Professional | | $629.85 | $1,204.83 | $2,575.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.22 / $1,204.83 / $2,575.15
| Professional | | $860.22 | $1,204.83 | $2,575.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.44 / $1,111.59 / $3,160.71
| Professional | | $968.44 | $1,111.59 | $3,160.71 |