- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,311.65 / $2,585.85 / $4,870.79
| Facility | | $1,311.65 | $2,585.85 | $4,870.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.50 / $165.96 / $214.42
| Professional | | $131.50 | $165.96 | $214.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.04 / $227.97 / $318.30
| Professional | | $148.04 | $227.97 | $318.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.25 / $246.24 / $456.70
| Professional | | $173.25 | $246.24 | $456.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.85 / $247.50 / $481.60
| Professional | | $169.85 | $247.50 | $481.60 |