- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.00 / $1,200.00 / $5,441.52
| Professional | | $1,200.00 | $1,200.00 | $5,441.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,416.46 / $1,416.46 / $1,416.46
| Facility | | $1,416.46 | $1,416.46 | $1,416.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,901.50 / $1,901.50 / $1,901.50
| Professional | | $1,901.50 | $1,901.50 | $1,901.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,416.46 / $1,416.46 / $1,416.46
| Facility | | $1,416.46 | $1,416.46 | $1,416.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.00 / $295.00 / $1,901.50
| Professional | | $295.00 | $295.00 | $1,901.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.65 / $998.51 / $3,808.22
| Professional | | $369.65 | $998.51 | $3,808.22 |