- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $907.42 / $907.42 / $2,600.00
| Facility | | $907.42 | $907.42 | $2,600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,025.10 / $1,144.67 / $1,247.14
| Facility | | $1,025.10 | $1,144.67 | $1,247.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,103.26 / $1,103.26 / $1,103.26
| Facility | | $1,103.26 | $1,103.26 | $1,103.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,704.64 / $6,704.64 / $6,704.64
| Facility | | $6,704.64 | $6,704.64 | $6,704.64 |
- 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 |