- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,655.00 / $3,280.00 / $4,707.00
| Facility | | $1,655.00 | $3,280.00 | $4,707.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.72 / $227.72 / $227.72
| Facility | | $227.72 | $227.72 | $227.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.72 / $227.72 / $227.72
| Professional | | $227.72 | $227.72 | $227.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.42 / $216.64 / $259.56
| Professional | | $206.42 | $216.64 | $259.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.42 / $216.64 / $259.56
| Professional | | $206.42 | $216.64 | $259.56 |