- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $11,748.98 / $15,848.93
| Facility | | $2,398.83 | $11,748.98 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,238.72 / $3,019.95
| Professional | | $1,737.80 | $2,238.72 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,238.72 / $10,000.00
| Facility | | $1,479.11 | $2,238.72 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,344.23 / $2,398.83
| Facility | | $1,778.28 | $2,344.23 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,737.80 / $2,884.03
| Facility | | $1,288.25 | $1,737.80 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $6,165.95
| Facility | | $6,165.95 | $6,165.95 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $10,232.93 / $37,153.52
| Facility | | $2,454.71 | $10,232.93 | $37,153.52 |