- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $11,748.98 / $26,302.68
| Facility | | $5,011.87 | $11,748.98 | $26,302.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,471.29 / $25,118.86
| Facility | | $7,413.10 | $10,471.29 | $25,118.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $10,000.00 / $19,952.62
| Facility | | $8,128.31 | $10,000.00 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,365.16 / $8,128.31
| Facility | | $2,884.03 | $4,365.16 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,467.37 / $8,511.38
| Facility | | $1,584.89 | $3,467.37 | $8,511.38 |