- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,653.44 / $2,116.32 / $2,539.59
| Facility | | $1,653.44 | $2,116.32 | $2,539.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,351.23 / $4,620.00
| Professional | | $2,116.32 | $2,351.23 | $4,620.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,427.47 / $1,427.47 / $1,570.22
| Facility | | $1,427.47 | $1,427.47 | $1,570.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,571.54 / $2,116.32 / $2,116.32
| Facility | | $1,571.54 | $2,116.32 | $2,116.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,116.32
| Professional | | $2,116.32 | $2,116.32 | $2,116.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.67 / $2,116.32 / $2,751.22
| Professional | | $2,031.67 | $2,116.32 | $2,751.22 |