- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,168.69 / $7,079.46
| Facility | | $2,511.89 | $4,168.69 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,570.40 / $3,548.13
| Professional | | $2,511.89 | $2,570.40 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,467.37 / $7,079.46
| Facility | | $2,691.53 | $3,467.37 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $3,548.13
| Professional | | $2,511.89 | $2,511.89 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,511.89 / $4,073.80
| Facility | | $2,398.83 | $2,511.89 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $3,235.94
| Professional | | $2,511.89 | $2,511.89 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,630.27 / $4,466.84
| Facility | | $2,511.89 | $2,630.27 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,691.53 / $3,019.95
| Professional | | $2,511.89 | $2,691.53 | $3,019.95 |