- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,066.32 / $1,066.32 / $1,066.32
| Facility | | $1,066.32 | $1,066.32 | $1,066.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,692.86 / $6,337.44 / $11,491.08
| Facility | | $3,692.86 | $6,337.44 | $11,491.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,481.31 / $3,518.81 / $8,464.95
| Facility | | $2,481.31 | $3,518.81 | $8,464.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,017.13 / $3,217.03 / $6,665.33
| Facility | | $2,017.13 | $3,217.03 | $6,665.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,142.65 / $1,918.02 / $11,496.00
| Facility | | $1,142.65 | $1,918.02 | $11,496.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,028.00 / $11,496.00 / $21,528.00
| Facility | | $5,028.00 | $11,496.00 | $21,528.00 |