- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,513.56 / $5,495.41
| Facility | | $489.78 | $1,513.56 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,454.71 / $4,365.16
| Facility | | $1,513.56 | $2,454.71 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $501.19 / $645.65
| Facility | | $354.81 | $501.19 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $1,659.59
| Facility | | $676.08 | $676.08 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $4,677.35 / $10,000.00
| Facility | | $851.14 | $4,677.35 | $10,000.00 |