- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,235.94 / $10,000.00
| Facility | | $1,047.13 | $3,235.94 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,466.84 / $16,595.87
| Facility | | $3,715.35 | $4,466.84 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,412.54 / $3,019.95
| Professional | | $794.33 | $1,412.54 | $3,019.95 |
- 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
- $1,412.54 / $3,548.13 / $6,918.31
| Facility | | $1,412.54 | $3,548.13 | $6,918.31 |