- 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
- $2,403.46 / $2,729.25 / $2,729.25
| Professional | | $2,403.46 | $2,729.25 | $2,729.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,233.66 / $2,809.68 / $4,924.54
| Professional | | $2,233.66 | $2,809.68 | $4,924.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,170.00 / $5,170.00 / $5,170.00
| Facility | | $5,170.00 | $5,170.00 | $5,170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,120.44 / $2,815.24 / $6,290.85
| Professional | | $2,120.44 | $2,815.24 | $6,290.85 |