- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,819.70 / $3,467.37
| Facility | | $1,096.48 | $1,819.70 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,023.29 / $1,230.27
| Professional | | $776.25 | $1,023.29 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,445.44 / $1,659.59
| Professional | | $676.08 | $1,445.44 | $1,659.59 |
- 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
- $758.58 / $954.99 / $1,737.80
| Professional | | $758.58 | $954.99 | $1,737.80 |