- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,338.08 / $1,338.08 / $3,550.00
| Facility | | $1,338.08 | $1,338.08 | $3,550.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,382.46 / $1,571.80 / $1,712.50
| Facility | | $1,382.46 | $1,571.80 | $1,712.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,483.99 / $1,483.99 / $1,483.99
| Facility | | $1,483.99 | $1,483.99 | $1,483.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,643.47 / $11,643.47 / $11,643.47
| Facility | | $11,643.47 | $11,643.47 | $11,643.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,439.00 / $4,439.00 / $4,439.00
| Facility | | $4,439.00 | $4,439.00 | $4,439.00 |