- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,164.00 / $3,294.00 / $5,743.00
| Facility | | $2,164.00 | $3,294.00 | $5,743.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,707.20 / $2,707.20 / $2,707.20
| Professional | | $2,707.20 | $2,707.20 | $2,707.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.97 / $447.13 / $651.60
| Facility | | $340.97 | $447.13 | $651.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,556.00 / $4,495.00
| Facility | | $1,078.00 | $1,556.00 | $4,495.00 |