- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,286.78 / $1,286.78 / $1,936.94
| Facility | | $1,286.78 | $1,286.78 | $1,936.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,249.66 / $1,299.15
| Professional | | $1,237.28 | $1,249.66 | $1,299.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,237.28
| Professional | | $1,237.28 | $1,237.28 | $1,237.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,237.28
| Facility | | $1,237.28 | $1,237.28 | $1,237.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,237.28
| Professional | | $1,237.28 | $1,237.28 | $1,237.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,835.50
| Professional | | $1,237.28 | $1,237.28 | $1,835.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.30 / $1,237.28 / $1,312.51
| Professional | | $1,138.30 | $1,237.28 | $1,312.51 |