- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $695.20 / $1,850.00 / $4,392.00
| Facility | | $695.20 | $1,850.00 | $4,392.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,308.22 / $2,728.26 / $4,442.46
| Facility | | $1,308.22 | $2,728.26 | $4,442.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $577.74
| Facility | | $40.00 | $40.00 | $577.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,200.00 / $1,200.00 / $1,200.00
| Facility | | $1,200.00 | $1,200.00 | $1,200.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $470.00 / $1,429.00 / $4,123.00
| Facility | | $470.00 | $1,429.00 | $4,123.00 |