- 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
- $416.87 / $616.60 / $1,584.89
| Professional | | $416.87 | $616.60 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $549.54 / $954.99
| Professional | | $407.38 | $549.54 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $676.08 / $1,148.15
| Professional | | $181.97 | $676.08 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $12,022.64
| Facility | | $2,818.38 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $724.44 / $1,202.26
| Professional | | $489.78 | $724.44 | $1,202.26 |