- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,475.20 / $6,296.48 / $10,950.40
| Facility | | $5,475.20 | $6,296.48 | $10,950.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,270.66 / $4,653.92 / $5,310.94
| Professional | | $4,270.66 | $4,653.92 | $5,310.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.67 / $69.98 / $94.15
| Facility | | $57.67 | $69.98 | $94.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.69 / $515.80 / $3,552.58
| Professional | | $424.69 | $515.80 | $3,552.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,306.24 / $4,626.54 / $17,170.84
| Facility | | $4,306.24 | $4,626.54 | $17,170.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.58 / $2,299.58 / $3,285.12
| Professional | | $2,299.58 | $2,299.58 | $3,285.12 |