- 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
- $1,071.52 / $1,348.96 / $5,011.87
| Facility | | $1,071.52 | $1,348.96 | $5,011.87 |
- 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
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |