- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,713.90 / $2,713.90 / $2,713.90
| Facility | | $2,713.90 | $2,713.90 | $2,713.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,184.29 / $10,622.61 / $21,774.47
| Facility | | $4,184.29 | $10,622.61 | $21,774.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,644.62 / $9,422.90 / $22,668.06
| Facility | | $6,644.62 | $9,422.90 | $22,668.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,401.60 / $8,614.79 / $17,848.86
| Facility | | $5,401.60 | $8,614.79 | $17,848.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,418.44 / $4,586.49 / $6,811.82
| Facility | | $3,418.44 | $4,586.49 | $6,811.82 |
- 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 |