- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,816.00 / $5,816.00 / $6,907.00
| Facility | | $5,816.00 | $5,816.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,353.91 / $2,353.91 / $2,353.91
| Professional | | $2,353.91 | $2,353.91 | $2,353.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,309.05 / $2,435.25 / $3,641.19
| Professional | | $2,309.05 | $2,435.25 | $3,641.19 |
- 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
- $1,984.39 / $2,766.87 / $6,319.92
| Professional | | $1,984.39 | $2,766.87 | $6,319.92 |