- 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
- $336.60 / $336.60 / $336.60
| Professional | | $336.60 | $336.60 | $336.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.25 / $1,167.25 / $1,237.28
| Facility | | $1,167.25 | $1,167.25 | $1,237.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,575.79
| Professional | | $1,237.28 | $1,237.28 | $1,575.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.69 / $1,051.69 / $1,511.64
| Professional | | $1,051.69 | $1,051.69 | $1,511.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.97 / $1,237.28 / $2,005.36
| Professional | | $1,055.97 | $1,237.28 | $2,005.36 |