- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,090.30 / $8,511.38
| Facility | | $933.25 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,786.30 / $18,620.87
| Facility | | $3,890.45 | $4,786.30 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,174.90 / $3,548.13
| Professional | | $660.69 | $1,174.90 | $3,548.13 |
- 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
- $660.69 / $1,949.84 / $4,466.84
| Facility | | $660.69 | $1,949.84 | $4,466.84 |