- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,888.44 / $10,964.78
| Facility | | $1,202.26 | $5,888.44 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $6,760.83 / $7,413.10
| Facility | | $5,888.44 | $6,760.83 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,174.90 / $1,380.38
| Professional | | $933.25 | $1,174.90 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,659.59 / $2,454.71
| Professional | | $1,318.26 | $1,659.59 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,348.96 / $2,137.96
| Facility | | $977.24 | $1,348.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $1,318.26 / $10,000.00
| Facility | | $954.99 | $1,318.26 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $11,220.18 / $23,988.33
| Facility | | $6,456.54 | $11,220.18 | $23,988.33 |