- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $2,290.87 / $7,762.47
| Facility | | $851.14 | $2,290.87 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,235.94 / $13,803.84
| Facility | | $2,630.27 | $3,235.94 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,288.25 / $3,890.45
| Professional | | $776.25 | $1,288.25 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,290.87 / $4,897.79
| Facility | | $1,174.90 | $2,290.87 | $4,897.79 |