- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $3,090.30 / $23,442.29
| Facility | | $630.96 | $3,090.30 | $23,442.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $39,810.72 / $53,703.18
| Facility | | $4,073.80 | $39,810.72 | $53,703.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $10,000.00 / $10,232.93
| Facility | | $5,495.41 | $10,000.00 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $676.08 / $2,089.30
| Professional | | $380.19 | $676.08 | $2,089.30 |
- 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
- $4,570.88 / $30,199.52 / $74,131.02
| Facility | | $4,570.88 | $30,199.52 | $74,131.02 |