- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.11 / $6,456.54 / $10,000.00
| Facility | | $33.11 | $6,456.54 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.11 / $213.80 / $354.81
| Professional | | $33.11 | $213.80 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.88 / $57.54 / $524.81
| Facility | | $33.88 | $57.54 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $91.20 / $117.49
| Professional | | $52.48 | $91.20 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $93.33 / $416.87
| Professional | | $52.48 | $93.33 | $416.87 |