- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,690.92 / $1,690.92 / $1,690.92
| Facility | | $1,690.92 | $1,690.92 | $1,690.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,492.97 / $7,824.33 / $17,676.25
| Facility | | $3,492.97 | $7,824.33 | $17,676.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,502.74 / $6,385.45 / $15,361.06
| Facility | | $4,502.74 | $6,385.45 | $15,361.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,660.41 / $5,837.83 / $12,095.33
| Facility | | $3,660.41 | $5,837.83 | $12,095.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,508.54 / $3,719.56 / $8,689.00
| Facility | | $2,508.54 | $3,719.56 | $8,689.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,940.00 / $8,689.00 / $11,531.00
| Facility | | $3,940.00 | $8,689.00 | $11,531.00 |