- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $2,326.37
| Facility | | $2,326.37 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.36 / $2,326.37 / $2,326.37
| Professional | | $2,326.36 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,767.25 / $4,985.06 / $9,430.26
| Facility | | $2,767.25 | $4,985.06 | $9,430.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,166.71 / $2,166.71 / $2,280.76
| Professional | | $2,166.71 | $2,166.71 | $2,280.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.61 / $2,554.44 / $2,554.44
| Professional | | $96.61 | $2,554.44 | $2,554.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,313.52 / $2,326.37 / $2,736.91
| Facility | | $2,313.52 | $2,326.37 | $2,736.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,313.52 / $2,326.37 / $2,776.22
| Professional | | $2,313.52 | $2,326.37 | $2,776.22 |
- 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
- $2,349.17 / $2,772.03 / $2,904.29
| Professional | | $2,349.17 | $2,772.03 | $2,904.29 |