- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $757.18 / $2,784.00 / $7,125.00
| Facility | | $757.18 | $2,784.00 | $7,125.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,631.87 / $9,907.76 / $19,840.28
| Facility | | $4,631.87 | $9,907.76 | $19,840.28 |
- 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
- $818.68 / $1,265.23 / $3,158.83
| Professional | | $818.68 | $1,265.23 | $3,158.83 |
- 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
- $1,300.00 / $5,978.00 / $12,241.00
| Facility | | $1,300.00 | $5,978.00 | $12,241.00 |