- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,210.42 / $3,030.42 / $3,173.03
| Facility | | $2,210.42 | $3,030.42 | $3,173.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,139.23 / $2,210.42 / $3,173.03
| Professional | | $2,139.23 | $2,210.42 | $3,173.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $390.56 / $390.56 / $429.62
| Facility | | $390.56 | $390.56 | $429.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.10 / $318.10 / $318.10
| Professional | | $318.10 | $318.10 | $318.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.76 / $2,837.98 / $2,837.98
| Professional | | $287.76 | $2,837.98 | $2,837.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.31 / $1,255.33 / $2,283.92
| Professional | | $1,142.31 | $1,255.33 | $2,283.92 |