- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,222.22 / $1,222.22 / $1,222.22
| Facility | | $1,222.22 | $1,222.22 | $1,222.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,829.08 / $9,998.40 / $19,511.25
| Facility | | $5,829.08 | $9,998.40 | $19,511.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,257.88 / $4,620.07 / $11,114.21
| Facility | | $3,257.88 | $4,620.07 | $11,114.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,648.42 / $4,223.85 / $8,751.35
| Facility | | $2,648.42 | $4,223.85 | $8,751.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $2,317.37 / $3,500.00
| Facility | | $1,751.00 | $2,317.37 | $3,500.00 |
- 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 |