- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,857.07 / $1,857.07 / $2,061.35
| Facility | | $1,857.07 | $1,857.07 | $2,061.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.07 / $1,857.07 / $2,061.35
| Professional | | $1,857.07 | $1,857.07 | $2,061.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,767.00 / $1,767.50 / $1,767.50
| Facility | | $1,767.00 | $1,767.50 | $1,767.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $863.84 / $2,039.14 / $2,039.14
| Facility | | $863.84 | $2,039.14 | $2,039.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.14 / $2,039.14 / $2,039.14
| Professional | | $2,039.14 | $2,039.14 | $2,039.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $17.00 / $20.00
| Professional | | $17.00 | $17.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.28 / $2,017.58 / $2,161.44
| Professional | | $1,875.28 | $2,017.58 | $2,161.44 |