- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $1,995.26 / $7,762.47
| Facility | | $363.08 | $1,995.26 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,344.23 / $4,365.16
| Facility | | $1,995.26 | $2,344.23 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $338.84 / $1,288.25
| Professional | | $223.87 | $338.84 | $1,288.25 |
- 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
- $1,096.48 / $2,290.87 / $4,786.30
| Facility | | $1,096.48 | $2,290.87 | $4,786.30 |