- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $1,862.09 / $7,244.36
| Facility | | $549.54 | $1,862.09 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,623.41 / $7,244.36
| Facility | | $2,290.87 | $5,623.41 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $707.95 / $1,659.59
| Professional | | $407.38 | $707.95 | $1,659.59 |
- 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
- $1,288.25 / $3,548.13 / $7,585.78
| Facility | | $1,288.25 | $3,548.13 | $7,585.78 |