- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,073.00 / $3,073.00 / $4,338.00
| Facility | | $3,073.00 | $3,073.00 | $4,338.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,575.67 / $1,575.67 / $1,575.67
| Professional | | $1,575.67 | $1,575.67 | $1,575.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,575.67 / $2,662.88 / $4,317.34
| Facility | | $1,575.67 | $2,662.88 | $4,317.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,471.64 / $1,716.91 / $2,364.42
| Facility | | $1,471.64 | $1,716.91 | $2,364.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |