- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $453.75 / $1,300.00 / $3,500.00
| Facility | | $453.75 | $1,300.00 | $3,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,601.67 / $4,715.26 / $6,578.64
| Facility | | $2,601.67 | $4,715.26 | $6,578.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $347.90 / $2,268.82 / $2,268.82
| Facility | | $347.90 | $2,268.82 | $2,268.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $425.00 / $425.00 / $425.00
| Facility | | $425.00 | $425.00 | $425.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $746.00 / $2,415.00 / $7,085.00
| Facility | | $746.00 | $2,415.00 | $7,085.00 |