- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.06 / $3,183.35 / $3,183.35
| Facility | | $297.06 | $3,183.35 | $3,183.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.06 / $297.06 / $448.77
| Professional | | $297.06 | $297.06 | $448.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,183.35 / $3,183.35 / $3,183.35
| Facility | | $3,183.35 | $3,183.35 | $3,183.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.41 / $370.52 / $511.31
| Professional | | $296.41 | $370.52 | $511.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,183.35 / $3,183.35 / $3,183.35
| Facility | | $3,183.35 | $3,183.35 | $3,183.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.24 / $343.69 / $388.00
| Professional | | $224.24 | $343.69 | $388.00 |