- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.92 / $1,003.26 / $1,366.76
| Professional | | $697.92 | $1,003.26 | $1,366.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $877.56 / $1,134.66 / $1,189.97
| Professional | | $877.56 | $1,134.66 | $1,189.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $642.26 / $642.26 / $642.26
| Facility | | $642.26 | $642.26 | $642.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.91 / $642.26 / $661.53
| Professional | | $545.91 | $642.26 | $661.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $697.92 / $1,321.04 / $8,276.54
| Facility | | $697.92 | $1,321.04 | $8,276.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.75 / $865.06 / $1,571.66
| Professional | | $612.75 | $865.06 | $1,571.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.20 / $865.06 / $1,585.66
| Professional | | $630.20 | $865.06 | $1,585.66 |