- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,316.00 / $6,316.00 / $6,907.00
| Facility | | $6,316.00 | $6,316.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.75 / $1,518.69 / $1,518.69
| Professional | | $1,336.75 | $1,518.69 | $1,518.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.54 / $1,552.63 / $2,675.84
| Professional | | $1,329.54 | $1,552.63 | $2,675.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,530.00
| Facility | | $2,000.00 | $2,000.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,276.13 / $1,627.43 / $3,496.88
| Professional | | $1,276.13 | $1,627.43 | $3,496.88 |