- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $5,888.44
| Facility | | $5,888.44 | $5,888.44 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,943.28 / $13,803.84
| Facility | | $4,786.30 | $7,943.28 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,782.79 / $23,442.29 / $24,547.09
| Facility | | $17,782.79 | $23,442.29 | $24,547.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $13,489.63
| Facility | | $5,888.44 | $5,888.44 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $9,332.54 / $13,803.84
| Facility | | $6,456.54 | $9,332.54 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $8,709.64 / $9,332.54
| Facility | | $6,760.83 | $8,709.64 | $9,332.54 |