- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,547.54 / $1,734.32 / $2,069.17
| Facility | | $1,547.54 | $1,734.32 | $2,069.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.15 / $1,415.58 / $1,734.32
| Professional | | $1,369.15 | $1,415.58 | $1,734.32 |
- 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
- $1,977.00 / $2,095.62 / $2,510.79
| Professional | | $1,977.00 | $2,095.62 | $2,510.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.06 / $1,643.60 / $2,042.30
| Facility | | $1,370.06 | $1,643.60 | $2,042.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.32 / $1,342.67 / $1,342.67
| Professional | | $183.32 | $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 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |