- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $6,025.60 / $21,379.62
| Facility | | $2,630.27 | $6,025.60 | $21,379.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $9,772.37 / $22,908.68
| Facility | | $6,918.31 | $9,772.37 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $9,332.54 / $18,197.01
| Facility | | $7,413.10 | $9,332.54 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,981.07 / $7,413.10
| Facility | | $2,511.89 | $3,981.07 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,467.37 / $8,511.38
| Facility | | $1,584.89 | $3,467.37 | $8,511.38 |