- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $814.00 / $814.00 / $1,876.68
| Facility | | $814.00 | $814.00 | $1,876.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.00 / $988.26 / $990.00
| Professional | | $814.00 | $988.26 | $990.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $337.10 / $429.58 / $678.68
| Facility | | $337.10 | $429.58 | $678.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.00 / $900.00 / $1,372.50
| Professional | | $900.00 | $900.00 | $1,372.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.74 / $111.05 / $324.22
| Facility | | $86.74 | $111.05 | $324.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.51 / $736.38 / $1,280.00
| Professional | | $40.51 | $736.38 | $1,280.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $814.00 / $814.00 / $1,367.52
| Facility | | $814.00 | $814.00 | $1,367.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,818.00 / $1,818.00 / $1,818.00
| Professional | | $1,818.00 | $1,818.00 | $1,818.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.24 / $40.24 / $40.24
| Facility | | $40.24 | $40.24 | $40.24 |