- 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
- $549.54 / $602.56 / $1,412.54
| Professional | | $549.54 | $602.56 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $512.86 / $933.25
| Professional | | $436.52 | $512.86 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $676.08 / $1,174.90
| Professional | | $457.09 | $676.08 | $1,174.90 |
- 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
- $398.11 / $575.44 / $870.96
| Professional | | $398.11 | $575.44 | $870.96 |