- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.68 / $4,118.00 / $7,212.00
| Facility | | $209.68 | $4,118.00 | $7,212.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $970.00 / $4,118.00 / $8,240.00
| Facility | | $970.00 | $4,118.00 | $8,240.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.73 / $227.15 / $270.83
| Facility | | $174.73 | $227.15 | $270.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $761.00 / $4,118.00 / $4,118.00
| Facility | | $761.00 | $4,118.00 | $4,118.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $900.00 / $3,817.00 / $5,402.00
| Facility | | $900.00 | $3,817.00 | $5,402.00 |