- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,089.30 / $13,803.84
| Facility | | $1,659.59 | $2,089.30 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,513.56 / $2,041.74
| Professional | | $1,174.90 | $1,513.56 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,412.54 / $2,818.38
| Facility | | $812.83 | $1,412.54 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,548.82 / $1,659.59
| Facility | | $1,174.90 | $1,548.82 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,202.26 / $1,995.26
| Facility | | $831.76 | $1,202.26 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,232.93 / $12,022.64
| Facility | | $7,413.10 | $10,232.93 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $10,000.00 / $14,454.40
| Facility | | $1,995.26 | $10,000.00 | $14,454.40 |