- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $973.77 / $973.77 / $973.77
| Facility | | $973.77 | $973.77 | $973.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.77 / $973.77 / $1,194.00
| Professional | | $973.77 | $973.77 | $1,194.00 |
- 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
- $1,420.02 / $1,420.02 / $1,420.02
| Professional | | $1,420.02 | $1,420.02 | $1,420.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,679.77 / $1,679.77 / $1,679.77
| Professional | | $1,679.77 | $1,679.77 | $1,679.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $5,351.82 / $9,239.00
| Facility | | $83.43 | $5,351.82 | $9,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,345.16 / $1,345.16 / $1,518.48
| Professional | | $1,345.16 | $1,345.16 | $1,518.48 |
- 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
- $1,420.02 / $1,420.02 / $1,420.02
| Professional | | $1,420.02 | $1,420.02 | $1,420.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,345.16 / $1,345.16 / $1,345.16
| Professional | | $1,345.16 | $1,345.16 | $1,345.16 |