- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.84 / $373.84 / $1,700.00
| Facility | | $373.84 | $373.84 | $1,700.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $396.25 / $437.42 / $476.58
| Facility | | $396.25 | $437.42 | $476.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $424.00 / $424.00 / $424.00
| Facility | | $424.00 | $424.00 | $424.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,099.20 / $1,099.20 / $4,738.39
| Facility | | $1,099.20 | $1,099.20 | $4,738.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,450.00 / $2,450.00 / $2,450.00
| Facility | | $2,450.00 | $2,450.00 | $2,450.00 |