- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,028.50 / $2,273.32 / $2,712.25
| Facility | | $2,028.50 | $2,273.32 | $2,712.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,786.05 / $1,845.88 / $2,273.32
| Professional | | $1,786.05 | $1,845.88 | $2,273.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.00 / $80.00 / $80.00
| Professional | | $80.00 | $80.00 | $80.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,349.75 / $2,490.73 / $2,984.18
| Professional | | $2,349.75 | $2,490.73 | $2,984.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,796.21 / $2,085.84 / $2,614.32
| Facility | | $1,796.21 | $2,085.84 | $2,614.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.70 / $1,465.70 / $1,465.70
| Professional | | $1,465.70 | $1,465.70 | $1,465.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |