- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,544.23 / $3,488.06 / $3,652.20
| Facility | | $2,544.23 | $3,488.06 | $3,652.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,451.53 / $3,115.58 / $3,652.20
| Professional | | $2,451.53 | $3,115.58 | $3,652.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $449.54 / $449.54 / $494.49
| Facility | | $449.54 | $449.54 | $494.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $366.13 / $366.13 / $366.13
| Professional | | $366.13 | $366.13 | $366.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.35 / $248.35 / $389.53
| Professional | | $248.35 | $248.35 | $389.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $233.80 / $2,517.41
| Professional | | $151.16 | $233.80 | $2,517.41 |