- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,110.00 / $2,330.00 / $5,691.00
| Facility | | $1,110.00 | $2,330.00 | $5,691.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $862.00 / $1,931.00 / $5,144.00
| Facility | | $862.00 | $1,931.00 | $5,144.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,652.00 / $1,652.00 / $1,652.00
| Facility | | $1,652.00 | $1,652.00 | $1,652.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.60 / $246.26 / $1,097.00
| Facility | | $149.60 | $246.26 | $1,097.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $247.00 / $760.00 / $1,351.00
| Facility | | $247.00 | $760.00 | $1,351.00 |