- 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
- $1,331.81 / $1,460.93 / $1,462.43
| Professional | | $1,331.81 | $1,460.93 | $1,462.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.30 / $1,566.24 / $2,504.55
| Professional | | $1,331.30 | $1,566.24 | $2,504.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,599.00 / $8,699.00 / $12,680.00
| Facility | | $3,599.00 | $8,699.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.43 / $1,359.50 / $2,251.06
| Professional | | $943.43 | $1,359.50 | $2,251.06 |