- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $625.00 / $2,536.00 / $7,500.00
| Facility | | $625.00 | $2,536.00 | $7,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $769.58 / $1,043.58 / $1,511.68
| Facility | | $769.58 | $1,043.58 | $1,511.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.44 / $189.44 / $189.44
| Facility | | $189.44 | $189.44 | $189.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.53 / $257.83 / $2,038.67
| Facility | | $108.53 | $257.83 | $2,038.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $352.00 / $1,265.00 / $2,637.00
| Facility | | $352.00 | $1,265.00 | $2,637.00 |