- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $9,120.11 / $16,595.87
| Facility | | $1,862.09 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,897.79 / $9,120.11
| Facility | | $2,818.38 | $4,897.79 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $1,621.81
| Facility | | $575.44 | $575.44 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Professional | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $794.33 / $1,122.02
| Facility | | $630.96 | $794.33 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $6,760.83 / $10,000.00
| Facility | | $1,698.24 | $6,760.83 | $10,000.00 |