- 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
- $2,137.96 / $2,818.38 / $7,079.46
| Professional | | $2,137.96 | $2,818.38 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,754.23 / $4,570.88
| Professional | | $2,454.71 | $2,754.23 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,890.45 / $5,623.41
| Professional | | $3,090.30 | $3,890.45 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $15,135.61
| Facility | | $3,715.35 | $7,762.47 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,311.31 / $6,025.60
| Professional | | $2,398.83 | $3,311.31 | $6,025.60 |