- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,925.83 / $4,155.41 / $6,135.09
| Facility | | $1,925.83 | $4,155.41 | $6,135.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.31 / $988.52 / $1,466.46
| Professional | | $859.31 | $988.52 | $1,466.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.44 / $1,202.85 / $2,165.14
| Professional | | $1,149.44 | $1,202.85 | $2,165.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.53 / $1,423.21 / $2,473.88
| Professional | | $874.53 | $1,423.21 | $2,473.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.64 / $1,115.59 / $1,521.27
| Professional | | $760.64 | $1,115.59 | $1,521.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.36 / $1,073.84 / $1,763.69
| Professional | | $775.36 | $1,073.84 | $1,763.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.45 / $1,148.58 / $1,435.74
| Professional | | $907.45 | $1,148.58 | $1,435.74 |