- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.13 / $2,678.00 / $7,602.00
| Facility | | $1,122.13 | $2,678.00 | $7,602.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,201.00 / $3,880.00 / $6,090.00
| Facility | | $2,201.00 | $3,880.00 | $6,090.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Facility | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $6,817.20 / $6,817.20
| Facility | | $55.00 | $6,817.20 | $6,817.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,794.00 / $3,626.00 / $6,291.00
| Facility | | $1,794.00 | $3,626.00 | $6,291.00 |