- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,857.07 / $1,857.07 / $1,857.07
| Facility | | $1,857.07 | $1,857.07 | $1,857.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.06 / $1,857.07 / $2,042.77
| Professional | | $1,857.06 | $1,857.07 | $2,042.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,494.66 / $1,813.84 / $2,440.19
| Facility | | $1,494.66 | $1,813.84 | $2,440.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,813.38 / $1,820.66 / $1,820.66
| Professional | | $1,813.38 | $1,820.66 | $1,820.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,039.14 / $2,039.14 / $2,039.14
| Facility | | $2,039.14 | $2,039.14 | $2,039.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.14 / $2,039.14 / $2,364.46
| Professional | | $2,039.14 | $2,039.14 | $2,364.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.28 / $2,119.07 / $2,123.77
| Professional | | $1,875.28 | $2,119.07 | $2,123.77 |