- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,000.00 / $1,000.00
| Professional | | $954.99 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,202.26 / $1,202.26
| Professional | | $776.25 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.82 / $169.82 / $1,071.52
| Facility | | $169.82 | $169.82 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $912.01 / $1,071.52
| Professional | | $169.82 | $912.01 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $977.24 / $1,288.25
| Facility | | $128.82 | $977.24 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,023.29 / $1,698.24
| Professional | | $812.83 | $1,023.29 | $1,698.24 |