- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,997.75 / $1,997.75 / $2,283.15
| Facility | | $1,997.75 | $1,997.75 | $2,283.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,997.75 / $2,283.15
| Professional | | $1,902.62 | $1,997.75 | $2,283.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,902.62
| Facility | | $1,902.62 | $1,902.62 | $1,902.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,902.62
| Professional | | $1,902.62 | $1,902.62 | $1,902.62 |
- 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
- $1,807.49 / $1,902.62 / $2,473.41
| Professional | | $1,807.49 | $1,902.62 | $2,473.41 |