- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.89 / $408.70 / $1,400.00
| Facility | | $170.89 | $408.70 | $1,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.36 / $200.83 / $218.81
| Facility | | $180.36 | $200.83 | $218.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.20 / $289.20 / $289.20
| Facility | | $289.20 | $289.20 | $289.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,867.12 / $1,867.12 / $1,867.12
| Facility | | $1,867.12 | $1,867.12 | $1,867.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,225.00 / $1,225.00 / $1,225.00
| Facility | | $1,225.00 | $1,225.00 | $1,225.00 |