- 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
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $10,471.29 / $18,197.01
| Facility | | $8,912.51 | $10,471.29 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,412.54 / $4,168.69
| Professional | | $891.25 | $1,412.54 | $4,168.69 |
- 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
- $2,089.30 / $5,370.32 / $12,302.69
| Facility | | $2,089.30 | $5,370.32 | $12,302.69 |