- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $7,244.36
| Facility | | $4,897.79 | $4,897.79 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $512.86 / $1,122.02
| Professional | | $416.87 | $512.86 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $575.44 / $758.58
| Professional | | $389.05 | $575.44 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $537.03 / $776.25
| Professional | | $416.87 | $537.03 | $776.25 |