- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $9,120.11 / $16,595.87
| Facility | | $1,122.02 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,128.61 / $9,120.11
| Facility | | $2,344.23 | $5,128.61 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $724.44 / $5,754.40
| Facility | | $575.44 | $724.44 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $707.95 / $1,000.00
| Professional | | $707.95 | $707.95 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $575.44 / $977.24
| Facility | | $416.87 | $575.44 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $13,182.57 / $23,988.33
| Facility | | $2,344.23 | $13,182.57 | $23,988.33 |