- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,317.00 / $2,317.00 / $2,918.72
| Facility | | $2,317.00 | $2,317.00 | $2,918.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.88 / $798.38 / $798.38
| Professional | | $693.88 | $798.38 | $798.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.54 / $478.54 / $478.54
| Facility | | $478.54 | $478.54 | $478.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.51 / $291.51 / $291.51
| Professional | | $291.51 | $291.51 | $291.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.40 / $440.40 / $440.40
| Professional | | $440.40 | $440.40 | $440.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,317.00 / $2,317.00 / $2,918.72
| Facility | | $2,317.00 | $2,317.00 | $2,918.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.88 / $798.38 / $798.38
| Professional | | $693.88 | $798.38 | $798.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.40 / $440.40 / $440.40
| Professional | | $440.40 | $440.40 | $440.40 |