- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,907.00 / $6,907.00 / $7,265.00
| Facility | | $6,907.00 | $6,907.00 | $7,265.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.32 / $1,009.14 / $1,009.14
| Professional | | $887.32 | $1,009.14 | $1,009.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.13 / $1,032.71 / $1,820.61
| Professional | | $882.13 | $1,032.71 | $1,820.61 |
- 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
- $832.96 / $982.06 / $2,320.83
| Professional | | $832.96 | $982.06 | $2,320.83 |