- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $4,073.80 / $10,000.00
| Facility | | $1,258.93 | $4,073.80 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $10,964.78 / $30,199.52
| Facility | | $9,120.11 | $10,964.78 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,290.87 / $6,165.95
| Professional | | $1,445.44 | $2,290.87 | $6,165.95 |
- 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
- $1,445.44 / $6,025.60 / $13,803.84
| Facility | | $1,445.44 | $6,025.60 | $13,803.84 |