- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,377.00 / $1,377.00 / $1,377.00
| Facility | | $1,377.00 | $1,377.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.50 / $1,377.00 / $1,377.00
| Professional | | $1,300.50 | $1,377.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.72 / $948.40 / $1,177.53
| Professional | | $758.72 | $948.40 | $1,177.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,377.00 / $1,377.00 / $1,377.00
| Facility | | $1,377.00 | $1,377.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.00 / $1,377.00 / $1,377.00
| Professional | | $1,377.00 | $1,377.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.30 / $1,377.00 / $1,377.00
| Professional | | $1,239.30 | $1,377.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,282.50 / $1,350.00 / $1,417.50
| Professional | | $1,282.50 | $1,350.00 | $1,417.50 |