- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $3,090.30 / $8,128.31
| Facility | | $616.60 | $3,090.30 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $831.76
| Facility | | $676.08 | $676.08 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,318.26
| Facility | | $1,096.48 | $1,096.48 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33,113.11 / $33,113.11 / $33,113.11
| Facility | | $33,113.11 | $33,113.11 | $33,113.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $10,964.78
| Facility | | $2,884.03 | $2,884.03 | $10,964.78 |