- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Facility | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,398.83
| Facility | | $1,737.80 | $1,737.80 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $13,803.84 / $13,803.84
| Facility | | $100.00 | $13,803.84 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,019.95
| Facility | | $2,570.40 | $2,570.40 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,047.13 / $1,737.80
| Facility | | $851.14 | $1,047.13 | $1,737.80 |