- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,875.00 / $3,038.00 / $4,387.00
| Facility | | $1,875.00 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.00 / $1,875.00 / $1,875.00
| Professional | | $1,875.00 | $1,875.00 | $1,875.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.87 / $1,798.87 / $1,798.87
| Professional | | $1,798.87 | $1,798.87 | $1,798.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $1,843.10
| Professional | | $45.00 | $45.00 | $1,843.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,292.00 / $4,455.00 / $13,847.00
| Facility | | $1,292.00 | $4,455.00 | $13,847.00 |