- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,514.76 / $3,526.86 / $12,615.00
| Facility | | $1,514.76 | $3,526.86 | $12,615.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $606.10 / $606.10 / $606.10
| Facility | | $606.10 | $606.10 | $606.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,514.76 / $2,187.92 / $2,891.18
| Facility | | $1,514.76 | $2,187.92 | $2,891.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,015.00 / $15,545.00 / $22,780.00
| Facility | | $4,015.00 | $15,545.00 | $22,780.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $19,167.16 / $19,167.16
| Facility | | $55.00 | $19,167.16 | $19,167.16 |