- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,176.13 / $2,517.12 / $3,634.92
| Facility | | $1,176.13 | $2,517.12 | $3,634.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.57 / $1,240.27 / $1,270.80
| Professional | | $1,029.57 | $1,240.27 | $1,270.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.26 / $1,055.33 / $2,057.64
| Professional | | $936.26 | $1,055.33 | $2,057.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,561.01 / $2,561.01 / $2,561.01
| Facility | | $2,561.01 | $2,561.01 | $2,561.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.46 / $1,430.43 / $2,750.00
| Professional | | $892.46 | $1,430.43 | $2,750.00 |