- 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
- $2,327.42 / $2,651.41 / $2,651.41
| Professional | | $2,327.42 | $2,651.41 | $2,651.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.58 / $2,744.16 / $4,734.26
| Professional | | $2,168.58 | $2,744.16 | $4,734.26 |
- 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
- $2,250.33 / $2,989.04 / $6,188.40
| Professional | | $2,250.33 | $2,989.04 | $6,188.40 |