- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,073.00 / $3,073.00 / $4,338.00
| Facility | | $3,073.00 | $3,073.00 | $4,338.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.00 / $65.00 / $65.00
| Professional | | $65.00 | $65.00 | $65.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.37 / $109.85 / $178.10
| Facility | | $93.37 | $109.85 | $178.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,343.53 / $21,947.03 / $22,507.38
| Facility | | $16,343.53 | $21,947.03 | $22,507.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $5,357.00
| Facility | | $5,357.00 | $5,357.00 | $5,357.00 |