- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,325.00 / $1,325.00 / $1,325.00
| Facility | | $1,325.00 | $1,325.00 | $1,325.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $642.86 / $3,747.03 / $4,973.58
| Facility | | $642.86 | $3,747.03 | $4,973.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,089.00 / $2,049.94 / $5,011.78
| Facility | | $1,089.00 | $2,049.94 | $5,011.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,398.60 / $3,485.31
| Facility | | $1,275.00 | $1,398.60 | $3,485.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,148.36 / $3,648.26 / $3,990.71
| Facility | | $2,148.36 | $3,648.26 | $3,990.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $750.00 / $1,000.00 / $5,873.12
| Facility | | $750.00 | $1,000.00 | $5,873.12 |