- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,786.30 / $10,471.29
| Facility | | $1,023.29 | $4,786.30 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $741.31
| Facility | | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,548.82
| Professional | | $1,122.02 | $1,122.02 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $870.96 / $1,348.96
| Facility | | $645.65 | $870.96 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $9,332.54 / $14,454.40
| Facility | | $3,311.31 | $9,332.54 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,952.62 / $19,952.62 / $33,884.42
| Facility | | $19,952.62 | $19,952.62 | $33,884.42 |