- 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
- $724.44 / $831.76 / $2,187.76
| Professional | | $724.44 | $831.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $812.83 / $1,445.44
| Professional | | $707.95 | $812.83 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,202.26 / $1,621.81
| Professional | | $891.25 | $1,202.26 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $977.24 / $1,778.28
| Professional | | $676.08 | $977.24 | $1,778.28 |