- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,374.87 / $2,374.87 / $2,436.05
| Facility | | $2,374.87 | $2,374.87 | $2,436.05 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $124.22 / $124.22 / $239.74
| Facility | | $124.22 | $124.22 | $239.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.48 / $114.10 / $124.22
| Professional | | $106.48 | $114.10 | $124.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.70 / $1,107.70 / $1,107.70
| Professional | | $1,107.70 | $1,107.70 | $1,107.70 |