- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,582.96 / $1,725.04
| Facility | | $1,452.25 | $1,582.96 | $1,725.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,597.48
| Professional | | $1,452.25 | $1,452.25 | $1,597.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.87 / $238.87 / $1,725.04
| Professional | | $238.87 | $238.87 | $1,725.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Facility | | $1,452.25 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Professional | | $1,452.25 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.89 / $1,575.56 / $3,000.00
| Professional | | $194.89 | $1,575.56 | $3,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.38 / $127.38 / $127.38
| Professional | | $127.38 | $127.38 | $127.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Professional | | $1,452.25 | $1,452.25 | $1,452.25 |