- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,416.69 / $1,416.69 / $1,823.65
| Facility | | $1,416.69 | $1,416.69 | $1,823.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $140.12 / $208.11
| Professional | | $138.74 | $140.12 | $208.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $138.74 / $138.74
| Professional | | $138.74 | $138.74 | $138.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.74 / $138.74 / $138.74
| Facility | | $138.74 | $138.74 | $138.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $138.74 / $138.74
| Professional | | $138.74 | $138.74 | $138.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $138.74 / $138.74
| Professional | | $138.74 | $138.74 | $138.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,416.69 / $1,416.69 / $1,823.65
| Facility | | $1,416.69 | $1,416.69 | $1,823.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $144.29 / $242.79
| Professional | | $138.74 | $144.29 | $242.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $138.74 / $208.11
| Professional | | $138.74 | $138.74 | $208.11 |