- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,812.22 / $2,867.91
| Facility | | $2,784.38 | $2,812.22 | $2,867.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $3,062.82
| Professional | | $2,784.38 | $2,784.38 | $3,062.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.92 / $101.92 / $152.88
| Facility | | $101.92 | $101.92 | $152.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.92 / $101.92 / $103.96
| Professional | | $101.92 | $101.92 | $103.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.37 / $121.37 / $121.37
| Facility | | $121.37 | $121.37 | $121.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,626.77 / $2,626.77 / $2,784.38
| Facility | | $2,626.77 | $2,626.77 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,784.38
| Professional | | $2,784.38 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,645.61 / $2,784.38 / $3,396.94
| Professional | | $2,645.61 | $2,784.38 | $3,396.94 |