- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,659.59 / $2,454.71
| Facility | | $1,071.52 | $1,659.59 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,047.13 / $1,348.96
| Professional | | $870.96 | $1,047.13 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,380.38 / $1,905.46
| Professional | | $831.76 | $1,380.38 | $1,905.46 |
- 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 / $1,071.52 / $1,737.80
| Professional | | $812.83 | $1,071.52 | $1,737.80 |