- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $1,071.52 / $1,905.46
| Professional | | $436.52 | $1,071.52 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $112.20 / $112.20
| Professional | | $60.26 | $112.20 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,071.52 / $1,698.24
| Facility | | $1,000.00 | $1,071.52 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |