- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $1,227.04
| Facility | | $1,227.04 | $1,227.04 | $1,227.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $1,507.00
| Professional | | $1,227.04 | $1,227.04 | $1,507.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,040.58 / $1,632.34 / $3,140.82
| Facility | | $1,040.58 | $1,632.34 | $3,140.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $2,270.02
| Facility | | $1,227.04 | $1,227.04 | $2,270.02 |