- 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
- $831.76 / $1,023.29 / $1,230.27
| Professional | | $831.76 | $1,023.29 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,412.54 / $1,698.24
| Professional | | $676.08 | $1,412.54 | $1,698.24 |
- 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
- $794.33 / $933.25 / $1,698.24
| Professional | | $794.33 | $933.25 | $1,698.24 |