- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $762.00 / $1,850.00 / $3,945.00
| Facility | | $762.00 | $1,850.00 | $3,945.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,401.36 / $4,505.10 / $8,157.79
| Facility | | $2,401.36 | $4,505.10 | $8,157.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Facility | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $848.00 / $848.00 / $848.00
| Facility | | $848.00 | $848.00 | $848.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $826.00 / $2,653.00 / $6,661.00
| Facility | | $826.00 | $2,653.00 | $6,661.00 |