- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,294.00 / $3,294.00 / $3,294.00
| Facility | | $3,294.00 | $3,294.00 | $3,294.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,799.28 / $5,266.29 / $7,095.63
| Facility | | $1,799.28 | $5,266.29 | $7,095.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,371.00 / $1,371.00 / $1,371.00
| Facility | | $1,371.00 | $1,371.00 | $1,371.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $961.00 / $961.00 / $961.00
| Facility | | $961.00 | $961.00 | $961.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $961.00 / $961.00 / $1,004.00
| Facility | | $961.00 | $961.00 | $1,004.00 |