- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,117.44 / $2,117.44 / $2,117.44
| Facility | | $2,117.44 | $2,117.44 | $2,117.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,577.45 / $4,848.37 / $9,101.62
| Facility | | $3,577.45 | $4,848.37 | $9,101.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,117.44 / $3,678.00 / $7,856.00
| Facility | | $2,117.44 | $3,678.00 | $7,856.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,986.62 / $4,300.77 / $5,627.75
| Facility | | $2,986.62 | $4,300.77 | $5,627.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,054.00 / $4,317.00 / $13,909.00
| Facility | | $3,054.00 | $4,317.00 | $13,909.00 |