- 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
- $2,951.21 / $3,890.45 / $10,232.93
| Professional | | $2,951.21 | $3,890.45 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,801.89 / $6,309.57
| Professional | | $3,235.94 | $3,801.89 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,623.41 / $7,943.28
| Professional | | $4,265.80 | $5,623.41 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $15,135.61
| Facility | | $3,235.94 | $7,413.10 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,677.35 / $8,317.64
| Professional | | $3,311.31 | $4,677.35 | $8,317.64 |