- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $776.25 / $2,089.30
| Facility | | $758.58 | $776.25 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $1,949.84
| Professional | | $758.58 | $758.58 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,318.26 / $2,691.53
| Professional | | $870.96 | $1,318.26 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $4,677.35 / $4,677.35
| Facility | | $891.25 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Professional | | $2,398.83 | $2,398.83 | $2,398.83 |