- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.26 / $1,047.26 / $1,047.26
| Facility | | $1,047.26 | $1,047.26 | $1,047.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,156.39 / $5,483.97 / $13,675.19
| Facility | | $2,156.39 | $5,483.97 | $13,675.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,798.84 / $3,969.11 / $9,548.23
| Facility | | $2,798.84 | $3,969.11 | $9,548.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,275.26 / $3,628.72 / $7,518.29
| Facility | | $2,275.26 | $3,628.72 | $7,518.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $2,097.00 / $3,823.25
| Facility | | $1,751.00 | $2,097.00 | $3,823.25 |
- 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 |