- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,819.70 / $3,467.37
| Facility | | $1,380.38 | $1,819.70 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,174.90 / $1,412.54
| Professional | | $977.24 | $1,174.90 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,621.81 / $1,949.84
| Professional | | $776.25 | $1,621.81 | $1,949.84 |
- 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
- $912.01 / $1,096.48 / $1,949.84
| Professional | | $912.01 | $1,096.48 | $1,949.84 |