- 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
- $870.96 / $954.99 / $2,238.72
| Professional | | $870.96 | $954.99 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $776.25 / $1,479.11
| Professional | | $660.69 | $776.25 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,023.29 / $1,819.70
| Professional | | $691.83 | $1,023.29 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $8,709.64
| Facility | | $2,570.40 | $4,677.35 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $912.01 / $1,380.38
| Professional | | $630.96 | $912.01 | $1,380.38 |