- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,338.00 / $4,338.00 / $4,338.00
| Facility | | $4,338.00 | $4,338.00 | $4,338.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,028.12 / $18,028.12 / $18,028.12
| Professional | | $18,028.12 | $18,028.12 | $18,028.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,571.00 / $30,467.52 / $49,397.05
| Facility | | $6,571.00 | $30,467.52 | $49,397.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,823.29 / $17,823.29 / $20,793.83
| Facility | | $17,823.29 | $17,823.29 | $20,793.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,571.00 / $6,571.00 / $6,571.00
| Facility | | $6,571.00 | $6,571.00 | $6,571.00 |