- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $6,918.31 / $25,703.96
| Facility | | $707.95 | $6,918.31 | $25,703.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42,657.95 / $42,657.95 / $42,657.95
| Facility | | $42,657.95 | $42,657.95 | $42,657.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $363.08 / $630.96
| Facility | | $288.40 | $363.08 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $812.83 / $1,949.84
| Facility | | $363.08 | $812.83 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Facility | | $7,585.78 | $7,585.78 | $7,585.78 |