- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $5,128.61 / $7,762.47
| Facility | | $1,819.70 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $1,819.70
| Professional | | $1,258.93 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,466.84 / $9,549.93
| Professional | | $2,290.87 | $4,466.84 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Professional | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $16,218.10 / $26,915.35
| Facility | | $2,344.23 | $16,218.10 | $26,915.35 |