- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,375.96 / $1,410.37 / $1,410.37
| Facility | | $1,375.96 | $1,410.37 | $1,410.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,358.93 / $1,410.37 / $1,714.81
| Professional | | $1,358.93 | $1,410.37 | $1,714.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.00 / $60.00 / $64.00
| Facility | | $15.00 | $60.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.96 / $58.27 / $1,342.49
| Professional | | $45.96 | $58.27 | $1,342.49 |
- 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
- $1,700.75 / $1,700.75 / $1,700.75
| Facility | | $1,700.75 | $1,700.75 | $1,700.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.75 / $1,700.75 / $1,700.75
| Professional | | $1,700.75 | $1,700.75 | $1,700.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $555.00 / $555.00 / $597.00
| Facility | | $555.00 | $555.00 | $597.00 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $1,342.67 / $1,342.67 / $1,503.78
| Professional | | $1,342.67 | $1,342.67 | $1,503.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.67 / $1,342.67 / $1,503.78
| Professional | | $1,342.67 | $1,342.67 | $1,503.78 |