- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,187.76
| Facility | | $1,737.80 | $1,737.80 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $3,162.28
| Professional | | $1,737.80 | $1,737.80 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,122.02 / $1,380.38
| Facility | | $1,000.00 | $1,122.02 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $199.53 / $346.74
| Professional | | $100.00 | $199.53 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $2,089.30
| Facility | | $660.69 | $660.69 | $2,089.30 |