- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $4,570.88
| Facility | | $4,570.88 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $7,244.36 / $11,220.18
| Facility | | $4,466.84 | $7,244.36 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,803.84 / $18,197.01 / $19,054.61
| Facility | | $13,803.84 | $18,197.01 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $10,715.19 / $11,220.18
| Facility | | $4,570.88 | $10,715.19 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $7,413.10 / $10,715.19
| Facility | | $5,128.61 | $7,413.10 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $6,760.83 / $7,413.10
| Facility | | $5,370.32 | $6,760.83 | $7,413.10 |