- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,145.78 / $7,838.38
| Facility | | $1,000.00 | $2,145.78 | $7,838.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.98 / $627.98 / $1,559.20
| Professional | | $627.98 | $627.98 | $1,559.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,887.20 / $38,113.58 / $60,686.30
| Facility | | $15,887.20 | $38,113.58 | $60,686.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $7,473.60
| Professional | | $60.00 | $60.00 | $7,473.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $775.00 / $35,986.00 / $35,986.00
| Facility | | $775.00 | $35,986.00 | $35,986.00 |