- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,888.44 / $10,964.78
| Facility | | $1,737.80 | $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
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,698.24 / $2,187.76
| Professional | | $1,412.54 | $1,698.24 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,344.23 / $2,511.89
| Professional | | $2,089.30 | $2,344.23 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $3,162.28
| Facility | | $1,479.11 | $2,089.30 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,089.30 / $10,000.00
| Facility | | $1,412.54 | $2,089.30 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $9,549.93 / $19,054.61
| Facility | | $5,623.41 | $9,549.93 | $19,054.61 |