- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $760.00 / $3,683.00 / $7,500.00
| Facility | | $760.00 | $3,683.00 | $7,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,064.77 / $6,457.50 / $10,202.77
| Facility | | $4,064.77 | $6,457.50 | $10,202.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.78 / $2,545.78 / $2,545.78
| Facility | | $2,545.78 | $2,545.78 | $2,545.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.45 / $443.12 / $5,543.93
| Facility | | $287.45 | $443.12 | $5,543.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $884.00 / $3,363.00 / $6,167.00
| Facility | | $884.00 | $3,363.00 | $6,167.00 |