- 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
- $958.19 / $1,092.22 / $1,092.22
| Professional | | $958.19 | $1,092.22 | $1,092.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.96 / $1,243.49 / $2,161.58
| Professional | | $957.96 | $1,243.49 | $2,161.58 |
- 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
- $908.43 / $1,234.71 / $2,456.17
| Professional | | $908.43 | $1,234.71 | $2,456.17 |