- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,543.89 / $2,543.89 / $2,608.16
| Facility | | $2,543.89 | $2,543.89 | $2,608.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $3,129.79
| Professional | | $2,608.16 | $2,608.16 | $3,129.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,921.89 / $2,332.31 / $3,137.71
| Facility | | $1,921.89 | $2,332.31 | $3,137.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,608.16
| Professional | | $2,608.16 | $2,608.16 | $2,608.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,608.16
| Facility | | $2,608.16 | $2,608.16 | $2,608.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $3,321.71
| Professional | | $2,608.16 | $2,608.16 | $3,321.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.43 / $2,673.43 / $3,261.58
| Facility | | $2,673.43 | $2,673.43 | $3,261.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,216.94 / $2,608.16 / $2,842.89
| Professional | | $2,216.94 | $2,608.16 | $2,842.89 |