- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,207.04 / $2,207.04 / $2,207.04
| Facility | | $2,207.04 | $2,207.04 | $2,207.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $2,092.88 / $2,378.28
| Professional | | $1,902.62 | $2,092.88 | $2,378.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.42 / $2,737.88 / $5,591.05
| Facility | | $100.42 | $2,737.88 | $5,591.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,902.62
| Professional | | $1,902.62 | $1,902.62 | $1,902.62 |
- 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
- $1,883.59 / $2,092.88 / $2,092.88
| Professional | | $1,883.59 | $2,092.88 | $2,092.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,902.62
| Professional | | $1,902.62 | $1,902.62 | $1,902.62 |