- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,133.41 / $1,768.96 / $4,255.47
| Facility | | $1,133.41 | $1,768.96 | $4,255.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.64 / $1,662.69 / $2,376.29
| Professional | | $986.64 | $1,662.69 | $2,376.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $982.20 / $1,614.29 / $3,350.76
| Facility | | $982.20 | $1,614.29 | $3,350.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.38 / $1,458.93 / $2,010.16
| Professional | | $886.38 | $1,458.93 | $2,010.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $555.00 / $780.18 / $1,411.83
| Facility | | $555.00 | $780.18 | $1,411.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,562.42 / $2,562.42 / $2,562.42
| Professional | | $2,562.42 | $2,562.42 | $2,562.42 |