- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $755.68 / $755.68 / $1,719.13
| Facility | | $755.68 | $755.68 | $1,719.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.00 / $812.28 / $893.51
| Professional | | $720.00 | $812.28 | $893.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.00 / $1,628.10 / $1,640.25
| Professional | | $1,377.00 | $1,628.10 | $1,640.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.54 / $524.75 / $659.83
| Professional | | $519.54 | $524.75 | $659.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $755.68 / $755.68 / $1,284.66
| Facility | | $755.68 | $755.68 | $1,284.66 |