- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,884.03 / $2,884.03
| Facility | | $1,000.00 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $177.83 / $309.03
| Professional | | $158.49 | $177.83 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $138.04 / $194.98
| Professional | | $138.04 | $138.04 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $173.78 / $208.93
| Professional | | $117.49 | $173.78 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $208.93 / $416.87
| Professional | | $125.89 | $208.93 | $416.87 |