- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,821.21 / $2,821.21 / $2,821.21
| Facility | | $2,821.21 | $2,821.21 | $2,821.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,166.47 / $10,629.47 / $23,246.03
| Facility | | $4,166.47 | $10,629.47 | $23,246.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,532.60 / $10,195.70 / $24,527.13
| Facility | | $6,532.60 | $10,195.70 | $24,527.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,661.08 / $9,304.24 / $19,312.70
| Facility | | $5,661.08 | $9,304.24 | $19,312.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,684.62 / $4,558.34 / $8,590.78
| Facility | | $2,684.62 | $4,558.34 | $8,590.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $796.00 / $3,500.00 / $8,152.00
| Facility | | $796.00 | $3,500.00 | $8,152.00 |