- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $742.27 / $1,350.93 / $1,484.54
| Facility | | $742.27 | $1,350.93 | $1,484.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.39 / $1,350.93 / $1,484.54
| Professional | | $586.39 | $1,350.93 | $1,484.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $742.27 / $742.27 / $742.27
| Facility | | $742.27 | $742.27 | $742.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.27 / $742.27 / $742.27
| Professional | | $742.27 | $742.27 | $742.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.75 / $445.36 / $1,113.41
| Professional | | $311.75 | $445.36 | $1,113.41 |