- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,698.24 / $2,454.71
| Facility | | $1,202.26 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,071.52 / $1,479.11
| Professional | | $954.99 | $1,071.52 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,659.59 / $2,041.74
| Professional | | $602.56 | $1,659.59 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,071.52 / $2,570.40
| Facility | | $371.54 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,258.93 / $1,995.26
| Professional | | $891.25 | $1,258.93 | $1,995.26 |