- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $1,741.80 / $3,580.72
| Facility | | $318.75 | $1,741.80 | $3,580.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $450.00
| Professional | | $318.75 | $318.75 | $450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.13 / $385.88 / $492.92
| Professional | | $357.13 | $385.88 | $492.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $783.28 / $1,534.80 / $2,149.56
| Facility | | $783.28 | $1,534.80 | $2,149.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,338.15 / $1,338.15 / $1,338.15
| Professional | | $1,338.15 | $1,338.15 | $1,338.15 |
- 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
- $1,438.18 / $1,438.18 / $1,438.18
| Professional | | $1,438.18 | $1,438.18 | $1,438.18 |