- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.58 / $5,248.07 / $10,000.00
| Facility | | $0.58 | $5,248.07 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $794.33 / $3,630.78
| Professional | | $316.23 | $794.33 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $97.72 / $97.72
| Professional | | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $758.58 / $1,949.84
| Facility | | $177.83 | $758.58 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $56.23 / $56.23
| Facility | | $56.23 | $56.23 | $56.23 |