- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,698.24 / $2,454.71
| Facility | | $1,258.93 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $1,318.26
| Professional | | $933.25 | $1,122.02 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,513.56 / $1,819.70
| Professional | | $724.44 | $1,513.56 | $1,819.70 |
- 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
- $851.14 / $1,023.29 / $1,862.09
| Professional | | $851.14 | $1,023.29 | $1,862.09 |