- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.00 / $3,140.00 / $6,907.00
| Facility | | $3,140.00 | $3,140.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.44 / $205.87 / $249.84
| Professional | | $190.44 | $205.87 | $249.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.75 / $280.89 / $365.83
| Professional | | $206.75 | $280.89 | $365.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $500.00
| Facility | | $500.00 | $500.00 | $500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.21 / $295.61 / $579.84
| Professional | | $231.21 | $295.61 | $579.84 |