- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,068.38 / $2,068.38 / $2,363.86
| Facility | | $2,068.38 | $2,068.38 | $2,363.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.89 / $2,068.38 / $2,363.86
| Professional | | $1,969.89 | $2,068.38 | $2,363.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,969.89 / $1,969.89 / $1,969.89
| Facility | | $1,969.89 | $1,969.89 | $1,969.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.89 / $1,969.89 / $1,969.89
| Professional | | $1,969.89 | $1,969.89 | $1,969.89 |
- 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
- $1,871.40 / $1,969.89 / $2,560.86
| Professional | | $1,871.40 | $1,969.89 | $2,560.86 |