- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,168.69 / $10,000.00
| Facility | | $1,023.29 | $4,168.69 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $12,022.64 / $22,908.68
| Facility | | $4,466.84 | $12,022.64 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,513.56 / $4,365.16
| Professional | | $851.14 | $1,513.56 | $4,365.16 |
- 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 |