- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,218.00 / $3,795.64 / $7,119.04
| Facility | | $2,218.00 | $3,795.64 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.05 / $175.03 / $433.63
| Professional | | $110.05 | $175.03 | $433.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.91 / $257.64 / $4,262.50
| Facility | | $149.91 | $257.64 | $4,262.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.76 / $257.64 / $368.13
| Facility | | $177.76 | $257.64 | $368.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,559.00 / $4,663.00 / $7,305.00
| Facility | | $2,559.00 | $4,663.00 | $7,305.00 |