- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,132.45 / $3,422.00 / $7,182.00
| Facility | | $1,132.45 | $3,422.00 | $7,182.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,132.00 / $3,728.00 / $5,774.00
| Facility | | $2,132.00 | $3,728.00 | $5,774.00 |
- 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
- $2,213.71 / $8,957.00 / $26,542.00
| Facility | | $2,213.71 | $8,957.00 | $26,542.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,934.00 / $4,611.00 / $8,086.00
| Facility | | $2,934.00 | $4,611.00 | $8,086.00 |