- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $663.00 / $1,193.00 / $2,100.00
| Facility | | $663.00 | $1,193.00 | $2,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.41 / $1,560.41 / $1,560.41
| Professional | | $1,560.41 | $1,560.41 | $1,560.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.63 / $525.63 / $525.63
| Facility | | $525.63 | $525.63 | $525.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $567.00 / $567.00 / $567.00
| Professional | | $567.00 | $567.00 | $567.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $824.95 / $1,560.41
| Facility | | $100.00 | $824.95 | $1,560.41 |