- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,096.48
| Professional | | $1,047.13 | $1,047.13 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $275.42 / $275.42
| Professional | | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $186.21 / $891.25
| Professional | | $131.83 | $186.21 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $302.00 / $1,000.00
| Professional | | $125.89 | $302.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $186.21 / $302.00
| Professional | | $151.36 | $186.21 | $302.00 |