- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $952.94 / $952.94 / $1,002.43
| Facility | | $952.94 | $952.94 | $1,002.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $829.83 / $829.83 / $952.94
| Professional | | $829.83 | $829.83 | $952.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,331.00 / $3,830.00 / $3,830.00
| Professional | | $2,331.00 | $3,830.00 | $3,830.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.88 / $1,135.45 / $3,061.13
| Professional | | $824.88 | $1,135.45 | $3,061.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.86 / $1,597.36 / $2,736.81
| Professional | | $846.86 | $1,597.36 | $2,736.81 |