- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $3,981.07
| Facility | | $1,380.38 | $1,380.38 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $147.91 / $295.12
| Professional | | $67.61 | $147.91 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $128.82 / $251.19
| Professional | | $69.18 | $128.82 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $154.88 / $346.74
| Professional | | $83.18 | $154.88 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,511.89 / $6,025.60
| Facility | | $1,380.38 | $2,511.89 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $151.36 / $275.42
| Professional | | $77.62 | $151.36 | $275.42 |