- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,698.24 / $2,454.71
| Facility | | $1,288.25 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,230.27 / $1,380.38
| Professional | | $954.99 | $1,230.27 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,548.82 / $1,949.84
| Professional | | $794.33 | $1,548.82 | $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
- $891.25 / $1,096.48 / $2,041.74
| Professional | | $891.25 | $1,096.48 | $2,041.74 |