- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.00 / $1,520.00 / $3,685.00
| Facility | | $400.00 | $1,520.00 | $3,685.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,040.32 / $3,863.65 / $5,427.06
| Facility | | $1,040.32 | $3,863.65 | $5,427.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $200.32
| Facility | | $40.00 | $40.00 | $200.32 |
- 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
- $194.00 / $543.00 / $1,560.00
| Facility | | $194.00 | $543.00 | $1,560.00 |