- 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
- $602.56 / $724.44 / $1,949.84
| Professional | | $602.56 | $724.44 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $724.44 / $1,174.90
| Professional | | $645.65 | $724.44 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $977.24 / $1,513.56
| Professional | | $812.83 | $977.24 | $1,513.56 |
- 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
- $588.84 / $870.96 / $1,584.89
| Professional | | $588.84 | $870.96 | $1,584.89 |