- 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
- $676.08 / $758.58 / $1,995.26
| Professional | | $676.08 | $758.58 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $758.58 / $1,288.25
| Professional | | $676.08 | $758.58 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,230.27 / $1,584.89
| Professional | | $851.14 | $1,230.27 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,244.36 / $13,182.57
| Facility | | $3,235.94 | $7,244.36 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $954.99 / $1,659.59
| Professional | | $660.69 | $954.99 | $1,659.59 |