- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $465.24 / $2,095.00 / $5,549.00
| Facility | | $465.24 | $2,095.00 | $5,549.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,535.64 / $3,284.80 / $6,577.81
| Facility | | $1,535.64 | $3,284.80 | $6,577.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.02 / $410.77 / $1,130.82
| Professional | | $284.02 | $410.77 | $1,130.82 |
- 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 |