- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $770.04 / $1,752.99 / $6,067.35
| Facility | | $770.04 | $1,752.99 | $6,067.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.74 / $35.74 / $60.88
| Professional | | $35.74 | $35.74 | $60.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.06 / $45.06 / $45.06
| Professional | | $45.06 | $45.06 | $45.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.94 / $74.93 / $163.69
| Facility | | $36.94 | $74.93 | $163.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.23 / $31.23 / $31.23
| Professional | | $31.23 | $31.23 | $31.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.10 / $35.10 / $35.10
| Professional | | $35.10 | $35.10 | $35.10 |