- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,002.67 / $5,978.00 / $9,512.00
| Facility | | $1,002.67 | $5,978.00 | $9,512.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,186.06 / $3,143.25 / $5,292.58
| Facility | | $1,186.06 | $3,143.25 | $5,292.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,109.96 / $1,109.96 / $1,109.96
| Facility | | $1,109.96 | $1,109.96 | $1,109.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $806.78 / $806.78 / $1,918.46
| Facility | | $806.78 | $806.78 | $1,918.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $773.91 / $1,137.56 / $1,743.97
| Professional | | $773.91 | $1,137.56 | $1,743.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,323.00 / $4,594.00 / $7,647.00
| Facility | | $1,323.00 | $4,594.00 | $7,647.00 |