- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,171.90 / $2,171.90 / $2,482.17
| Facility | | $2,171.90 | $2,171.90 | $2,482.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,171.90 / $2,482.17
| Professional | | $2,068.46 | $2,171.90 | $2,482.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.60 / $273.60 / $273.60
| Professional | | $273.60 | $273.60 | $273.60 |
- 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
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,965.05 / $2,068.46 / $2,689.01
| Professional | | $1,965.05 | $2,068.46 | $2,689.01 |