- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,190.44 / $1,190.44 / $1,348.64
| Facility | | $1,190.44 | $1,190.44 | $1,348.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,361.01
| Professional | | $1,237.28 | $1,237.28 | $1,361.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.56 / $336.60 / $336.60
| Professional | | $106.56 | $336.60 | $336.60 |
- 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
- $179.61 / $1,342.34 / $1,680.00
| Professional | | $179.61 | $1,342.34 | $1,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.38 / $127.38 / $127.38
| Professional | | $127.38 | $127.38 | $127.38 |
- 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 |