- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $606.51 / $606.51 / $606.51
| Facility | | $606.51 | $606.51 | $606.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.05 / $606.51 / $1,223.53
| Professional | | $112.05 | $606.51 | $1,223.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $606.51 / $1,030.00 / $1,957.65
| Facility | | $606.51 | $1,030.00 | $1,957.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.05 / $606.51 / $1,223.53
| Professional | | $112.05 | $606.51 | $1,223.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.00 / $697.80 / $1,163.00
| Professional | | $624.00 | $697.80 | $1,163.00 |