- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $128.82 / $128.82
| Facility | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,230.27
| Professional | | $1,047.13 | $1,047.13 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,000.00 / $1,000.00
| Professional | | $851.14 | $1,000.00 | $1,000.00 |
- 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
- $1,047.13 / $1,047.13 / $1,479.11
| Professional | | $1,047.13 | $1,047.13 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $302.00 / $1,000.00
| Professional | | $125.89 | $302.00 | $1,000.00 |