- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,147.08 / $2,147.08 / $2,147.08
| Facility | | $2,147.08 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.08 / $2,147.08 / $2,147.08
| Professional | | $2,147.08 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.14 / $263.14 / $394.73
| Facility | | $263.14 | $263.14 | $394.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,147.08 / $2,147.08 / $2,147.08
| Facility | | $2,147.08 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.08 / $2,147.08 / $3,207.99
| Professional | | $2,147.08 | $2,147.08 | $3,207.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.98 / $2,104.98 / $3,048.64
| Professional | | $2,104.98 | $2,104.98 | $3,048.64 |