- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $580.05 / $1,520.00 / $3,728.00
| Facility | | $580.05 | $1,520.00 | $3,728.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,695.45 / $3,140.45 / $4,797.76
| Facility | | $1,695.45 | $3,140.45 | $4,797.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.66 / $2,105.05 / $2,105.05
| Facility | | $376.66 | $2,105.05 | $2,105.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $725.00 / $725.00 / $725.00
| Facility | | $725.00 | $725.00 | $725.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $826.00 / $2,785.00 / $7,984.00
| Facility | | $826.00 | $2,785.00 | $7,984.00 |