- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,919.60 / $3,357.54 / $5,839.20
| Facility | | $2,919.60 | $3,357.54 | $5,839.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,277.29 / $3,357.54 / $3,357.54
| Professional | | $2,277.29 | $3,357.54 | $3,357.54 |
- 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 / $1,894.38
| Professional | | $371.80 | $451.58 | $1,894.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,296.27 / $2,467.06 / $9,155.86
| Facility | | $2,296.27 | $2,467.06 | $9,155.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,226.23 / $1,751.76
| Professional | | $1,226.23 | $1,226.23 | $1,751.76 |