- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,659.59 / $2,454.71
| Facility | | $1,174.90 | $1,659.59 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,047.13 / $1,258.93
| Professional | | $851.14 | $1,047.13 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,479.11 / $1,737.80
| Professional | | $691.83 | $1,479.11 | $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
- $812.83 / $954.99 / $1,737.80
| Professional | | $812.83 | $954.99 | $1,737.80 |