- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,905.46 / $2,290.87
| Facility | | $316.23 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $478.63
| Professional | | $316.23 | $316.23 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Professional | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,905.46 / $3,630.78
| Facility | | $316.23 | $1,905.46 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $588.84
| Professional | | $316.23 | $316.23 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Professional | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $371.54 / $977.24
| Facility | | $281.84 | $371.54 | $977.24 |