- 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
- $707.95 / $812.83 / $2,089.30
| Professional | | $707.95 | $812.83 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $724.44 / $1,202.26
| Professional | | $537.03 | $724.44 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $912.01 / $1,445.44
| Professional | | $181.97 | $912.01 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,570.88 / $7,585.78
| Facility | | $2,570.40 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $891.25 / $1,513.56
| Professional | | $630.96 | $891.25 | $1,513.56 |