- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $7,413.10 / $14,125.38
| Facility | | $5,754.40 | $7,413.10 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,379.62 / $21,379.62 / $22,387.21
| Facility | | $21,379.62 | $21,379.62 | $22,387.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $11,481.54
| Facility | | $5,370.32 | $5,370.32 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $7,943.28 / $8,709.64
| Facility | | $6,309.57 | $7,943.28 | $8,709.64 |