- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $301.31 / $1,017.00 / $5,091.00
| Facility | | $301.31 | $1,017.00 | $5,091.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $837.23 / $1,790.88 / $3,586.23
| Facility | | $837.23 | $1,790.88 | $3,586.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.27 / $758.09 / $1,668.33
| Professional | | $219.27 | $758.09 | $1,668.33 |
- 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
- $165.00 / $900.00 / $3,686.00
| Facility | | $165.00 | $900.00 | $3,686.00 |