- 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
- $2,187.76 / $2,511.89 / $6,456.54
| Professional | | $2,187.76 | $2,511.89 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,511.89 / $4,073.80
| Professional | | $2,137.96 | $2,511.89 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,890.45 / $5,370.32
| Professional | | $2,754.23 | $3,890.45 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,090.30 / $5,370.32
| Professional | | $2,187.76 | $3,090.30 | $5,370.32 |