- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $615.17 / $615.17 / $1,051.56
| Facility | | $615.17 | $615.17 | $1,051.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.17 / $1,051.56 / $1,051.56
| Professional | | $615.17 | $1,051.56 | $1,051.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.75 / $615.17 / $1,204.19
| Facility | | $269.75 | $615.17 | $1,204.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.17 / $752.62 / $1,051.56
| Professional | | $615.17 | $752.62 | $1,051.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.84 / $424.69 / $707.82
| Professional | | $383.84 | $424.69 | $707.82 |