- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,964.83 / $4,457.10
| Facility | | $2,016.42 | $2,964.83 | $4,457.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,391.63
| Professional | | $2,016.42 | $2,016.42 | $2,391.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.42 / $3,355.32 / $6,411.20
| Facility | | $2,016.42 | $3,355.32 | $6,411.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.29 / $2,016.42 / $2,016.42
| Facility | | $1,902.29 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,816.65 / $1,816.65 / $1,816.65
| Facility | | $1,816.65 | $1,816.65 | $1,816.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,235.91
| Professional | | $2,016.42 | $2,016.42 | $2,235.91 |