- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,057.90 / $1,057.90 / $1,057.90
| Facility | | $1,057.90 | $1,057.90 | $1,057.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,482.26 / $10,065.74 / $21,331.89
| Facility | | $5,482.26 | $10,065.74 | $21,331.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,468.09 / $3,852.05 / $9,266.62
| Facility | | $2,468.09 | $3,852.05 | $9,266.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,138.82 / $3,515.25 / $7,296.56
| Facility | | $2,138.82 | $3,515.25 | $7,296.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,118.73 / $1,891.85 / $3,363.30
| Facility | | $1,118.73 | $1,891.85 | $3,363.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $796.00 / $3,500.00 / $8,152.00
| Facility | | $796.00 | $3,500.00 | $8,152.00 |