- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.48 / $2,036.05 / $3,540.96
| Facility | | $1,770.48 | $2,036.05 | $3,540.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.98 / $2,036.05 / $2,036.05
| Professional | | $1,380.98 | $2,036.05 | $2,036.05 |
- 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
- $316.43 / $384.32 / $1,148.78
| Professional | | $316.43 | $384.32 | $1,148.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,392.48 / $1,496.05 / $5,552.46
| Facility | | $1,392.48 | $1,496.05 | $5,552.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,593.43 / $1,593.43 / $1,770.48
| Facility | | $1,593.43 | $1,593.43 | $1,770.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.60 / $743.60 / $1,062.29
| Professional | | $743.60 | $743.60 | $1,062.29 |