- 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
- $1,150.63 / $1,261.58 / $1,343.49
| Professional | | $1,150.63 | $1,261.58 | $1,343.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.47 / $1,353.49 / $2,279.10
| Professional | | $1,150.47 | $1,353.49 | $2,279.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $5,164.00 / $9,622.00
| Facility | | $3,146.00 | $5,164.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.33 / $1,223.06 / $1,943.63
| Professional | | $1,007.33 | $1,223.06 | $1,943.63 |