- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,250.00
| Facility | | $960.00 | $1,728.00 | $2,250.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,961.17 / $2,379.96 / $3,201.82
| Facility | | $1,961.17 | $2,379.96 | $3,201.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.00 / $385.00 / $385.00
| Professional | | $385.00 | $385.00 | $385.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,141.00 / $2,473.00
| Facility | | $375.00 | $1,141.00 | $2,473.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.76 / $130.76 / $195.44
| Professional | | $130.76 | $130.76 | $195.44 |