- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $3,981.07
| Facility | | $3,019.95 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $870.96 / $2,089.30
| Professional | | $660.69 | $870.96 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $794.33 / $1,318.26
| Professional | | $602.56 | $794.33 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,148.15 / $1,905.46
| Professional | | $954.99 | $1,148.15 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,148.15 / $1,905.46
| Professional | | $691.83 | $1,148.15 | $1,905.46 |