- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,630.78 / $10,715.19
| Facility | | $1,318.26 | $3,630.78 | $10,715.19 |
- 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
- $1,548.82 / $1,548.82 / $2,398.83
| Professional | | $1,548.82 | $1,548.82 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $1,995.26
| Facility | | $1,000.00 | $1,288.25 | $1,995.26 |
- 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 |