- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,553.75 / $2,553.75 / $2,553.75
| Facility | | $2,553.75 | $2,553.75 | $2,553.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,990.20 / $10,728.93 / $21,609.27
| Facility | | $4,990.20 | $10,728.93 | $21,609.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,673.49 / $8,045.71 / $19,355.05
| Facility | | $5,673.49 | $8,045.71 | $19,355.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,612.14 / $7,355.71 / $15,240.20
| Facility | | $4,612.14 | $7,355.71 | $15,240.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,378.00 / $4,077.47 / $6,784.03
| Facility | | $3,378.00 | $4,077.47 | $6,784.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $3,500.00 / $8,152.00
| Facility | | $1,751.00 | $3,500.00 | $8,152.00 |