- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,819.70 / $2,511.89
| Facility | | $1,174.90 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,071.52 / $1,258.93
| Professional | | $870.96 | $1,071.52 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,412.54 / $1,737.80
| Professional | | $691.83 | $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
- $831.76 / $977.24 / $1,778.28
| Professional | | $831.76 | $977.24 | $1,778.28 |