- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,574.65 / $2,960.85 / $5,149.30
| Facility | | $2,574.65 | $2,960.85 | $5,149.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,008.23 / $2,497.41 / $2,960.85
| Professional | | $2,008.23 | $2,497.41 | $2,960.85 |
- 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
- $371.80 / $451.58 / $1,670.56
| Professional | | $371.80 | $451.58 | $1,670.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,024.96 / $2,175.58 / $8,074.54
| Facility | | $2,024.96 | $2,175.58 | $8,074.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.34 / $1,081.34 / $1,544.79
| Professional | | $1,081.34 | $1,081.34 | $1,544.79 |