- 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
- $575.44 / $724.44 / $1,819.70
| Professional | | $575.44 | $724.44 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $630.96 / $1,047.13
| Professional | | $467.74 | $630.96 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $776.25 / $1,258.93
| Professional | | $181.97 | $776.25 | $1,258.93 |
- 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
- $537.03 / $794.33 / $1,174.90
| Professional | | $537.03 | $794.33 | $1,174.90 |