- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.75 / $2,056.00 / $4,933.00
| Facility | | $193.75 | $2,056.00 | $4,933.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $514.79 / $722.06 / $1,129.23
| Facility | | $514.79 | $722.06 | $1,129.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $258.85 / $258.85 / $258.85
| Facility | | $258.85 | $258.85 | $258.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $2,056.00 / $4,933.00
| Facility | | $500.00 | $2,056.00 | $4,933.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $773.00 / $3,005.00 / $4,504.00
| Facility | | $773.00 | $3,005.00 | $4,504.00 |