- 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
- $3,353.71 / $4,069.89 / $5,475.31
| Facility | | $3,353.71 | $4,069.89 | $5,475.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.00 / $25.00 / $552.00
| Professional | | $25.00 | $25.00 | $552.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $410.00 / $1,272.00 / $2,504.00
| Facility | | $410.00 | $1,272.00 | $2,504.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.15 / $503.15 / $752.05
| Professional | | $503.15 | $503.15 | $752.05 |