- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,168.69 / $10,000.00
| Facility | | $1,148.15 | $4,168.69 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,949.84 / $2,398.83
| Professional | | $1,230.27 | $1,949.84 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $199.53 / $1,905.46
| Professional | | $120.23 | $199.53 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $2,951.21 / $7,413.10
| Facility | | $575.44 | $2,951.21 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,659.59 / $4,073.80
| Professional | | $1,148.15 | $1,659.59 | $4,073.80 |