- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $5,011.87 / $12,589.25
| Facility | | $1,548.82 | $5,011.87 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $10,715.19 / $20,892.96
| Facility | | $8,128.31 | $10,715.19 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $7,943.28
| Facility | | $7,943.28 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,174.90 / $8,128.31
| Facility | | $758.58 | $1,174.90 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,995.26 / $2,511.89
| Professional | | $1,445.44 | $1,995.26 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $7,943.28
| Facility | | $7,943.28 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $8,511.38 / $10,000.00
| Facility | | $6,918.31 | $8,511.38 | $10,000.00 |