- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.87 / $350.08 / $1,200.00
| Facility | | $113.87 | $350.08 | $1,200.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.95 / $295.38 / $406.67
| Facility | | $243.95 | $295.38 | $406.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.17 / $391.17 / $391.17
| Facility | | $391.17 | $391.17 | $391.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,552.80 / $6,238.16 / $14,497.01
| Facility | | $2,552.80 | $6,238.16 | $14,497.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,910.00 / $2,910.00 / $2,910.00
| Facility | | $2,910.00 | $2,910.00 | $2,910.00 |