- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $663.07 / $663.07 / $1,319.51
| Facility | | $663.07 | $663.07 | $1,319.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.07 / $809.58 / $1,112.45
| Professional | | $663.07 | $809.58 | $1,112.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.35 / $1,049.35 / $1,426.03
| Professional | | $1,049.35 | $1,049.35 | $1,426.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $663.07 / $762.53 / $1,308.77
| Facility | | $663.07 | $762.53 | $1,308.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.07 / $1,308.77 / $5,826.31
| Professional | | $1,075.07 | $1,308.77 | $5,826.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.33 / $1,308.77 / $1,402.49
| Professional | | $1,243.33 | $1,308.77 | $1,402.49 |