- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,128.59 / $2,678.00 / $7,602.00
| Facility | | $1,128.59 | $2,678.00 | $7,602.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,695.00 / $5,486.00 / $9,283.00
| Facility | | $2,695.00 | $5,486.00 | $9,283.00 |
- 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
- $3,379.20 / $19,913.50 / $26,542.00
| Facility | | $3,379.20 | $19,913.50 | $26,542.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,870.00 / $8,273.00 / $12,407.00
| Facility | | $3,870.00 | $8,273.00 | $12,407.00 |