- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $748.07 / $1,636.41 / $2,631.93
| Facility | | $748.07 | $1,636.41 | $2,631.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.07 / $748.07 / $794.83
| Professional | | $748.07 | $748.07 | $794.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.83 / $794.83 / $794.83
| Facility | | $794.83 | $794.83 | $794.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.83 / $794.83 / $794.83
| Professional | | $794.83 | $794.83 | $794.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $150.00 / $345.40
| Professional | | $100.00 | $150.00 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |