- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,835.00 / $6,835.00 / $6,907.00
| Facility | | $6,835.00 | $6,835.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.28 / $2,245.69 / $2,245.69
| Professional | | $1,905.28 | $2,245.69 | $2,245.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,879.11 / $2,129.79 / $3,781.36
| Professional | | $1,879.11 | $2,129.79 | $3,781.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,783.00 / $2,783.00 / $2,783.00
| Facility | | $2,783.00 | $2,783.00 | $2,783.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.71 / $1,926.84 / $5,159.58
| Professional | | $1,761.71 | $1,926.84 | $5,159.58 |