- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.65 / $1,564.86 / $1,611.57
| Professional | | $1,374.65 | $1,564.86 | $1,611.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,623.58 / $1,634.92 / $2,024.42
| Professional | | $1,623.58 | $1,634.92 | $2,024.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.64 / $2,217.64 / $2,217.64
| Facility | | $2,217.64 | $2,217.64 | $2,217.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,884.99 / $2,217.64 / $3,059.25
| Professional | | $1,884.99 | $2,217.64 | $3,059.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,979.26 / $1,979.26 / $1,979.26
| Professional | | $1,979.26 | $1,979.26 | $1,979.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,024.85 / $1,324.07 / $2,206.78
| Professional | | $1,024.85 | $1,324.07 | $2,206.78 |