- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,670.07 / $1,670.07 / $1,670.07
| Facility | | $1,670.07 | $1,670.07 | $1,670.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.13 / $1,590.54 / $1,670.07
| Professional | | $127.13 | $1,590.54 | $1,670.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.65 / $1,988.18 / $2,692.53
| Professional | | $492.65 | $1,988.18 | $2,692.53 |
- 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 / $1,590.54
| Professional | | $1,590.54 | $1,590.54 | $1,590.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.20 / $1,638.26 / $3,000.00
| Facility | | $127.20 | $1,638.26 | $3,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.20 / $127.20 / $127.20
| Professional | | $127.20 | $127.20 | $127.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.30 / $1,590.54 / $1,853.66
| Professional | | $1,463.30 | $1,590.54 | $1,853.66 |