- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,448.30 / $2,237.34
| Professional | | $1,448.30 | $1,448.30 | $2,237.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.00 / $80.00 / $80.00
| Facility | | $80.00 | $80.00 | $80.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.37 / $198.37 / $198.37
| Professional | | $198.37 | $198.37 | $198.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,204.94 / $3,204.94 / $3,204.94
| Professional | | $3,204.94 | $3,204.94 | $3,204.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,448.30 / $2,436.38
| Facility | | $1,448.30 | $1,448.30 | $2,436.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,448.30 / $2,436.38
| Facility | | $1,448.30 | $1,448.30 | $2,436.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.37 / $198.37 / $198.37
| Professional | | $198.37 | $198.37 | $198.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.70 / $68.70 / $70.12
| Professional | | $68.70 | $68.70 | $70.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.09 / $78.09 / $105.42
| Professional | | $78.09 | $78.09 | $105.42 |