- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,715.35 / $10,000.00
| Facility | | $1,202.26 | $3,715.35 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,760.83 / $30,902.95
| Facility | | $5,011.87 | $6,760.83 | $30,902.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,089.30 / $4,897.79
| Professional | | $1,174.90 | $2,089.30 | $4,897.79 |
- 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
- $1,584.89 / $4,365.16 / $9,332.54
| Facility | | $1,584.89 | $4,365.16 | $9,332.54 |