- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,448.30 / $2,237.34
| Professional | | $1,448.30 | $1,448.30 | $2,237.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.45 / $1,500.00 / $1,500.00
| Professional | | $1,445.45 | $1,500.00 | $1,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.37 / $198.37 / $198.37
| Professional | | $198.37 | $198.37 | $198.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,448.30 / $2,436.38
| Professional | | $1,448.30 | $1,448.30 | $2,436.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.37 / $198.37 / $198.37
| Professional | | $198.37 | $198.37 | $198.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,364.75 / $1,364.75 / $1,364.75
| Facility | | $1,364.75 | $1,364.75 | $1,364.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.75 / $1,364.75 / $1,364.75
| Professional | | $1,364.75 | $1,364.75 | $1,364.75 |