- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,040.08 / $1,040.08 / $1,040.08
| Facility | | $1,040.08 | $1,040.08 | $1,040.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.08 / $1,040.08 / $1,331.32
| Professional | | $1,040.08 | $1,040.08 | $1,331.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.91 / $978.91 / $978.91
| Professional | | $978.91 | $978.91 | $978.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.08 / $1,040.08 / $1,040.08
| Professional | | $1,040.08 | $1,040.08 | $1,040.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.68 / $218.42 / $1,101.28
| Professional | | $151.68 | $218.42 | $1,101.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.70 / $1,019.70 / $1,080.88
| Professional | | $1,019.70 | $1,019.70 | $1,080.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.81 / $330.81 / $330.81
| Professional | | $330.81 | $330.81 | $330.81 |