- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,606.00 / $2,155.03 / $5,194.70
| Facility | | $1,606.00 | $2,155.03 | $5,194.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.74 / $35.74 / $41.21
| Professional | | $35.74 | $35.74 | $41.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.44 / $68.69 / $76.09
| Facility | | $54.44 | $68.69 | $76.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.06 / $45.06 / $45.06
| Professional | | $45.06 | $45.06 | $45.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.06 / $45.06 / $45.06
| Professional | | $45.06 | $45.06 | $45.06 |