- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,476.20 / $1,500.78 / $1,500.78
| Facility | | $1,476.20 | $1,500.78 | $1,500.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,358.93 / $1,398.77 / $1,714.81
| Professional | | $1,358.93 | $1,398.77 | $1,714.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.67 / $1,342.67 / $1,342.67
| Professional | | $1,342.67 | $1,342.67 | $1,342.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,996.77 / $2,095.62 / $2,510.79
| Professional | | $1,996.77 | $2,095.62 | $2,510.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,838.90 / $1,838.90 / $1,838.90
| Facility | | $1,838.90 | $1,838.90 | $1,838.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,838.90 / $1,838.90 / $1,838.90
| Professional | | $1,838.90 | $1,838.90 | $1,838.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.67 / $1,342.67 / $1,342.67
| Professional | | $1,342.67 | $1,342.67 | $1,342.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.67 / $1,342.67 / $1,342.67
| Professional | | $1,342.67 | $1,342.67 | $1,342.67 |