- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,921.90 / $2,921.90 / $2,921.90
| Facility | | $2,921.90 | $2,921.90 | $2,921.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,184.29 / $10,622.61 / $23,927.63
| Facility | | $4,184.29 | $10,622.61 | $23,927.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,182.83 / $10,186.14 / $24,504.14
| Facility | | $7,182.83 | $10,186.14 | $24,504.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,839.12 / $9,312.58 / $19,294.59
| Facility | | $5,839.12 | $9,312.58 | $19,294.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,455.00 / $4,938.01 / $7,465.86
| Facility | | $3,455.00 | $4,938.01 | $7,465.86 |
- 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 |