- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,623.41 / $15,135.61
| Facility | | $1,202.26 | $5,623.41 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,442.29 / $63,095.73 / $123,026.88
| Facility | | $23,442.29 | $63,095.73 | $123,026.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $7,585.78 / $10,471.29
| Professional | | $5,011.87 | $7,585.78 | $10,471.29 |
- 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 |