- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,483.69 / $1,686.00 / $4,348.79
| Professional | | $1,483.69 | $1,686.00 | $4,348.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,535.41 / $2,535.41 / $2,535.41
| Facility | | $2,535.41 | $2,535.41 | $2,535.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.35 / $2,535.41 / $2,863.44
| Professional | | $1,435.35 | $2,535.41 | $2,863.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,256.45 / $1,727.62 / $2,535.41
| Facility | | $1,256.45 | $1,727.62 | $2,535.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.04 / $2,535.41 / $3,343.20
| Professional | | $1,545.04 | $2,535.41 | $3,343.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,278.17 / $2,719.62 / $3,384.48
| Professional | | $2,278.17 | $2,719.62 | $3,384.48 |