- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,754.43 / $1,754.43 / $2,303.00
| Facility | | $1,754.43 | $1,754.43 | $2,303.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,754.43 / $1,816.09 / $1,997.67
| Professional | | $1,754.43 | $1,816.09 | $1,997.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.96 / $1,757.29 / $1,827.58
| Professional | | $1,317.96 | $1,757.29 | $1,827.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,349.75 / $2,349.75 / $2,937.19
| Professional | | $2,349.75 | $2,349.75 | $2,937.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,303.00 / $2,303.00 / $2,303.00
| Facility | | $2,303.00 | $2,303.00 | $2,303.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,754.43 / $1,816.09 / $2,016.70
| Professional | | $1,754.43 | $1,816.09 | $2,016.70 |