- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $249.75 / $1,520.00 / $3,685.00
| Facility | | $249.75 | $1,520.00 | $3,685.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.21 / $311.47 / $1,091.05
| Facility | | $129.21 | $311.47 | $1,091.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $55.68
| Facility | | $40.00 | $40.00 | $55.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.00 / $400.00 / $400.00
| Facility | | $400.00 | $400.00 | $400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.00 / $543.00 / $1,560.00
| Facility | | $194.00 | $543.00 | $1,560.00 |