- 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
- $1,819.70 / $2,691.53 / $12,882.50
| Professional | | $1,819.70 | $2,691.53 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $3,981.07
| Professional | | $1,778.28 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,311.31 / $5,754.40
| Professional | | $2,754.23 | $3,311.31 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,630.78 / $5,623.41
| Professional | | $2,137.96 | $3,630.78 | $5,623.41 |