- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,068.46
| Facility | | $2,068.46 | $2,068.46 | $2,068.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,275.32
| Professional | | $2,068.46 | $2,068.46 | $2,275.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,068.46
| Facility | | $2,068.46 | $2,068.46 | $2,068.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,068.46
| Professional | | $2,068.46 | $2,068.46 | $2,068.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,758.20 / $2,068.46 / $2,068.46
| Professional | | $1,758.20 | $2,068.46 | $2,068.46 |