- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,220.57
| Facility | | $2,068.46 | $2,068.46 | $2,220.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,220.57
| Professional | | $2,068.46 | $2,068.46 | $2,220.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,951.39 / $2,068.46 / $2,068.46
| Facility | | $1,951.39 | $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
- 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
- $1,034.24 / $2,068.46 / $2,068.46
| Professional | | $1,034.24 | $2,068.46 | $2,068.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $70.00
| Professional | | $40.00 | $40.00 | $70.00 |
- 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
- $2,068.46 / $2,220.57 / $2,220.57
| Professional | | $2,068.46 | $2,220.57 | $2,220.57 |