- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $5,011.87 / $8,317.64
| Facility | | $1,148.15 | $5,011.87 | $8,317.64 |
- 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
- $724.44 / $851.14 / $1,122.02
| Professional | | $724.44 | $851.14 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,412.54 / $1,819.70
| Professional | | $1,174.90 | $1,412.54 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,148.15 / $1,819.70
| Facility | | $794.33 | $1,148.15 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,202.26 / $10,000.00
| Facility | | $794.33 | $1,202.26 | $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 |