- 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
- $380.19 / $549.54 / $1,288.25
| Professional | | $380.19 | $549.54 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $512.86 / $933.25
| Professional | | $371.54 | $512.86 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $724.44 / $1,202.26
| Professional | | $501.19 | $724.44 | $1,202.26 |
- 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
- $416.87 / $645.65 / $1,096.48
| Professional | | $416.87 | $645.65 | $1,096.48 |