- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,907.00 / $6,907.00 / $6,907.00
| Facility | | $6,907.00 | $6,907.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.75 / $216.39 / $216.39
| Professional | | $171.75 | $216.39 | $216.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,759.64 / $2,759.64 / $2,759.64
| Facility | | $2,759.64 | $2,759.64 | $2,759.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,530.00 / $2,530.00 / $2,530.00
| Facility | | $2,530.00 | $2,530.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.32 / $329.83 / $616.63
| Professional | | $242.32 | $329.83 | $616.63 |