- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.40 / $1,377.00 / $1,377.00
| Professional | | $1,328.40 | $1,377.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $948.40 / $1,000.00 / $1,064.95
| Professional | | $948.40 | $1,000.00 | $1,064.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,377.00 / $1,377.00 / $1,377.00
| Facility | | $1,377.00 | $1,377.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.00 / $1,377.00 / $1,377.00
| Professional | | $1,377.00 | $1,377.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.00 / $1,593.19 / $2,444.04
| Professional | | $1,377.00 | $1,593.19 | $2,444.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.00 / $1,377.00 / $1,377.00
| Professional | | $1,377.00 | $1,377.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,350.00 / $2,142.61
| Professional | | $1,350.00 | $1,350.00 | $2,142.61 |