- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,361.60 / $2,361.60 / $3,456.00
| Facility | | $2,361.60 | $2,361.60 | $3,456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,304.00 / $2,448.00 / $3,456.00
| Professional | | $2,304.00 | $2,448.00 | $3,456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.25 / $55.25 / $55.25
| Professional | | $55.25 | $55.25 | $55.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.00 / $396.00 / $396.00
| Professional | | $396.00 | $396.00 | $396.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $25.00 / $50.00
| Professional | | $17.00 | $25.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,268.89 / $2,400.00 / $3,120.00
| Professional | | $2,268.89 | $2,400.00 | $3,120.00 |