- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.18 / $1,122.18 / $1,209.25
| Facility | | $1,122.18 | $1,122.18 | $1,209.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.63 / $411.15 / $483.70
| Professional | | $396.63 | $411.15 | $483.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.01 / $475.00 / $1,354.02
| Facility | | $380.01 | $475.00 | $1,354.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.08 / $411.14 / $443.38
| Professional | | $403.08 | $411.14 | $443.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $411.15 / $411.15 / $411.15
| Facility | | $411.15 | $411.15 | $411.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.15 / $411.15 / $411.15
| Professional | | $411.15 | $411.15 | $411.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.18 / $1,122.18 / $1,209.25
| Facility | | $1,122.18 | $1,122.18 | $1,209.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.63 / $411.15 / $483.70
| Professional | | $396.63 | $411.15 | $483.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.08 / $403.08 / $584.47
| Professional | | $403.08 | $403.08 | $584.47 |