- 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
- $4,570.88 / $12,302.69 / $23,442.29
| Facility | | $4,570.88 | $12,302.69 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,513.56 / $5,754.40
| Professional | | $891.25 | $1,513.56 | $5,754.40 |
- 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 / $2,884.03 / $7,413.10
| Facility | | $575.44 | $2,884.03 | $7,413.10 |