- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,709.95 / $3,116.44 / $5,419.90
| Facility | | $2,709.95 | $3,116.44 | $5,419.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.76 / $2,303.46 / $2,628.65
| Professional | | $2,113.76 | $2,303.46 | $2,628.65 |
- 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 / $1,758.35
| Professional | | $424.69 | $515.80 | $1,758.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,131.38 / $2,289.91 / $8,498.65
| Facility | | $2,131.38 | $2,289.91 | $8,498.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.18 / $1,138.18 / $1,625.97
| Professional | | $1,138.18 | $1,138.18 | $1,625.97 |