- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $623.85 / $2,418.00 / $5,260.00
| Facility | | $623.85 | $2,418.00 | $5,260.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,712.54 / $5,633.48 / $8,872.24
| Facility | | $2,712.54 | $5,633.48 | $8,872.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $408.22
| Facility | | $40.00 | $40.00 | $408.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,400.00 / $1,400.00
| Facility | | $1,400.00 | $1,400.00 | $1,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,141.00 / $4,717.00 / $11,696.00
| Facility | | $1,141.00 | $4,717.00 | $11,696.00 |