- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.00 / $2,448.00 / $5,150.00
| Facility | | $860.00 | $2,448.00 | $5,150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.19 / $3,773.96 / $5,613.80
| Facility | | $2,238.19 | $3,773.96 | $5,613.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,204.05 / $3,204.05 / $3,204.05
| Facility | | $3,204.05 | $3,204.05 | $3,204.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.00 / $400.00 / $400.00
| Facility | | $400.00 | $400.00 | $400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $746.00 / $2,420.00 / $7,085.00
| Facility | | $746.00 | $2,420.00 | $7,085.00 |