- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $345.62 / $345.62 / $1,700.00
| Facility | | $345.62 | $345.62 | $1,700.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $394.04 / $437.02 / $476.13
| Facility | | $394.04 | $437.02 | $476.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $425.10 / $425.10 / $425.10
| Facility | | $425.10 | $425.10 | $425.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30,078.11 / $30,078.11 / $30,078.11
| Facility | | $30,078.11 | $30,078.11 | $30,078.11 |
- 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 |