- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,380.38 / $2,041.74
| Professional | | $812.83 | $1,380.38 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $776.25 / $776.25
| Professional | | $776.25 | $776.25 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $7,762.47 / $8,511.38
| Facility | | $3,890.45 | $7,762.47 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,584.89 / $2,454.71
| Professional | | $912.01 | $1,584.89 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $977.24 / $2,630.27
| Professional | | $891.25 | $977.24 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Facility | | $630.96 | $630.96 | $630.96 |