- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.00 / $1,933.00 / $5,393.00
| Facility | | $630.00 | $1,933.00 | $5,393.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,295.45 / $8,494.15 / $18,526.82
| Facility | | $4,295.45 | $8,494.15 | $18,526.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.24 / $1,242.77 / $3,589.74
| Professional | | $839.24 | $1,242.77 | $3,589.74 |
- 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
- $1,600.00 / $4,530.00 / $8,566.00
| Facility | | $1,600.00 | $4,530.00 | $8,566.00 |