- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $807.66 / $2,095.00 / $5,393.00
| Facility | | $807.66 | $2,095.00 | $5,393.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,574.57 / $7,646.16 / $15,311.43
| Facility | | $3,574.57 | $7,646.16 | $15,311.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.00 / $875.00 / $908.00
| Facility | | $875.00 | $875.00 | $908.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.13 / $1,102.92 / $2,870.92
| Professional | | $683.13 | $1,102.92 | $2,870.92 |
- 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
- $578.00 / $2,873.00 / $7,384.00
| Facility | | $578.00 | $2,873.00 | $7,384.00 |