- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,258.93 / $1,288.25
| Professional | | $1,202.26 | $1,258.93 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $1,000.00 / $1,230.27
| Professional | | $154.88 | $1,000.00 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Professional | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $891.25 / $1,023.29
| Professional | | $154.88 | $891.25 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $134.90 / $1,258.93
| Professional | | $125.89 | $134.90 | $1,258.93 |