- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,056.76 / $2,056.76 / $2,714.92
| Facility | | $2,056.76 | $2,056.76 | $2,714.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,056.76 / $2,056.76 / $2,056.76
| Professional | | $2,056.76 | $2,056.76 | $2,056.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,851.08 / $1,851.08 / $2,776.62
| Facility | | $1,851.08 | $1,851.08 | $2,776.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,851.08 / $1,851.08 / $1,888.10
| Professional | | $1,851.08 | $1,851.08 | $1,888.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,456.45 / $1,456.45 / $1,456.45
| Facility | | $1,456.45 | $1,456.45 | $1,456.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $1,748.25
| Facility | | $1,748.25 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $1,748.25
| Professional | | $1,748.25 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.97 / $1,713.97 / $2,056.76
| Professional | | $1,713.97 | $1,713.97 | $2,056.76 |