- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.13 / $127.13 / $127.13
| Facility | | $127.13 | $127.13 | $127.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.13 / $127.13 / $1,670.07
| Professional | | $127.13 | $127.13 | $1,670.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.60 / $60.00 / $127.96
| Professional | | $45.60 | $60.00 | $127.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,500.51 / $1,590.54 / $1,590.54
| Facility | | $1,500.51 | $1,590.54 | $1,590.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $2,250.76
| Professional | | $1,590.54 | $1,590.54 | $2,250.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.13 / $127.20 / $3,300.00
| Facility | | $127.13 | $127.20 | $3,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.20 / $127.20 / $2,356.98
| Professional | | $127.20 | $127.20 | $2,356.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.10 / $2,326.10 / $2,326.10
| Professional | | $2,326.10 | $2,326.10 | $2,326.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $2,099.51
| Professional | | $1,590.54 | $1,590.54 | $2,099.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,550.00 / $2,623.11 / $5,246.22
| Facility | | $2,550.00 | $2,623.11 | $5,246.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,500.00 / $10,500.00 / $10,500.00
| Professional | | $10,500.00 | $10,500.00 | $10,500.00 |