- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,130.53 / $2,130.53 / $2,130.53
| Facility | | $2,130.53 | $2,130.53 | $2,130.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,130.53 / $2,130.53
| Professional | | $2,068.46 | $2,130.53 | $2,130.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.09 / $2,068.46 / $2,068.46
| Professional | | $199.09 | $2,068.46 | $2,068.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.60 / $2,068.46 / $2,130.53
| Facility | | $426.60 | $2,068.46 | $2,130.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,482.16
| Professional | | $2,068.46 | $2,068.46 | $2,482.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $264.08 / $3,330.85
| Professional | | $30.00 | $264.08 | $3,330.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,194.65
| Professional | | $2,068.46 | $2,068.46 | $2,194.65 |