- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,052.17 / $2,052.17 / $2,052.17
| Facility | | $2,052.17 | $2,052.17 | $2,052.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,166.47 / $10,086.08 / $18,946.47
| Facility | | $4,166.47 | $10,086.08 | $18,946.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,765.52 / $7,437.75 / $17,892.50
| Facility | | $4,765.52 | $7,437.75 | $17,892.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,129.75 / $6,787.43 / $14,088.59
| Facility | | $4,129.75 | $6,787.43 | $14,088.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,052.17 / $3,468.18 / $6,305.54
| Facility | | $2,052.17 | $3,468.18 | $6,305.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.00 / $3,312.00 / $7,770.00
| Facility | | $875.00 | $3,312.00 | $7,770.00 |