- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,096.48 / $1,096.48
| Facility | | $707.95 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $426.58 / $602.56
| Professional | | $371.54 | $426.58 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.39 / $3.98 / $3.98
| Professional | | $3.39 | $3.98 | $3.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Professional | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,096.48 / $1,096.48
| Facility | | $707.95 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $426.58 / $1,023.29
| Professional | | $371.54 | $426.58 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $3,311.31
| Professional | | $1,949.84 | $1,949.84 | $3,311.31 |