- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.01 / $1,149.49 / $1,339.21
| Professional | | $821.01 | $1,149.49 | $1,339.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $779.41 / $1,078.76 / $1,715.01
| Professional | | $779.41 | $1,078.76 | $1,715.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,007.00 / $6,315.00 / $12,945.00
| Facility | | $3,007.00 | $6,315.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.29 / $1,282.60 / $1,945.47
| Professional | | $798.29 | $1,282.60 | $1,945.47 |