- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,222.97 / $1,734.32 / $4,172.14
| Facility | | $1,222.97 | $1,734.32 | $4,172.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.02 / $1,672.10 / $2,368.12
| Professional | | $1,028.02 | $1,672.10 | $2,368.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $994.18 / $1,585.58 / $3,285.15
| Facility | | $994.18 | $1,585.58 | $3,285.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.02 / $1,487.16 / $1,970.80
| Professional | | $869.02 | $1,487.16 | $1,970.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $739.70 / $868.77 / $1,495.21
| Facility | | $739.70 | $868.77 | $1,495.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,156.21 / $4,156.21 / $4,156.21
| Professional | | $4,156.21 | $4,156.21 | $4,156.21 |