- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,961.00 / $1,961.00 / $1,961.00
| Facility | | $1,961.00 | $1,961.00 | $1,961.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.00 / $1,961.00 / $2,157.10
| Professional | | $1,961.00 | $1,961.00 | $2,157.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,961.00 / $1,961.00 / $1,961.00
| Facility | | $1,961.00 | $1,961.00 | $1,961.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.00 / $1,961.00 / $1,961.00
| Professional | | $1,961.00 | $1,961.00 | $1,961.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,764.90 / $1,961.00 / $2,120.82
| Professional | | $1,764.90 | $1,961.00 | $2,120.82 |