- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,374.87 / $2,374.87 / $2,374.87
| Facility | | $2,374.87 | $2,374.87 | $2,374.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,374.87 / $2,374.87 / $2,374.87
| Professional | | $2,374.87 | $2,374.87 | $2,374.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.48 / $112.57 / $114.10
| Professional | | $106.48 | $112.57 | $114.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,374.87 / $2,374.87 / $3,616.93
| Facility | | $2,374.87 | $2,374.87 | $3,616.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |