- 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 / $1,857.07
| Professional | | $1,857.06 | $1,857.07 | $1,857.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,820.66 / $1,838.87 / $2,275.83
| Professional | | $1,820.66 | $1,838.87 | $2,275.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,800.27 / $1,857.07 / $5,571.21
| Facility | | $1,800.27 | $1,857.07 | $5,571.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,036.65 / $2,062.81 / $2,123.77
| Professional | | $2,036.65 | $2,062.81 | $2,123.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.28 / $2,062.81 / $2,119.07
| Professional | | $1,875.28 | $2,062.81 | $2,119.07 |