- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.31 / $6,727.65 / $15,233.13
| Facility | | $21.31 | $6,727.65 | $15,233.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.31 / $21.31 / $21.52
| Professional | | $21.31 | $21.31 | $21.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.10 / $25.41 / $32.88
| Facility | | $20.10 | $25.41 | $32.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.31 / $21.31 / $21.31
| Professional | | $21.31 | $21.31 | $21.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.80 / $8,702.00 / $13,785.00
| Facility | | $47.80 | $8,702.00 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.06 / $22.06 / $22.06
| Professional | | $22.06 | $22.06 | $22.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.31 / $21.31 / $26.11
| Professional | | $21.31 | $21.31 | $26.11 |