- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,445.44 / $2,454.71
| Facility | | $1,071.52 | $1,445.44 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $891.25 / $1,230.27
| Professional | | $776.25 | $891.25 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,412.54 / $1,737.80
| Professional | | $602.56 | $1,412.54 | $1,737.80 |
- 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
- $758.58 / $1,071.52 / $1,698.24
| Professional | | $758.58 | $1,071.52 | $1,698.24 |