- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $793.83 / $4,376.00 / $12,600.00
| Facility | | $793.83 | $4,376.00 | $12,600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $984.20 / $1,450.76 / $3,055.34
| Facility | | $984.20 | $1,450.76 | $3,055.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $505.00 / $505.00 / $505.00
| Facility | | $505.00 | $505.00 | $505.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $619.83 / $968.38 / $5,565.00
| Facility | | $619.83 | $968.38 | $5,565.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $989.71 / $3,096.00 / $5,562.00
| Facility | | $989.71 | $3,096.00 | $5,562.00 |