- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $775.20 / $775.20 / $1,563.30
| Facility | | $775.20 | $775.20 | $1,563.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.20 / $886.92 / $1,086.28
| Professional | | $775.20 | $886.92 | $1,086.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.63 / $1,271.59 / $1,523.52
| Professional | | $1,199.63 | $1,271.59 | $1,523.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $775.20 / $1,302.75 / $1,602.40
| Facility | | $775.20 | $1,302.75 | $1,602.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.77 / $1,308.77 / $5,826.31
| Professional | | $1,308.77 | $1,308.77 | $5,826.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.77 / $1,308.77 / $1,421.39
| Professional | | $1,308.77 | $1,308.77 | $1,421.39 |