- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,736.00 / $4,736.00 / $6,907.00
| Facility | | $4,736.00 | $4,736.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.39 / $1,464.65 / $1,464.65
| Professional | | $1,287.39 | $1,464.65 | $1,464.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.97 / $1,438.01 / $2,666.52
| Professional | | $897.97 | $1,438.01 | $2,666.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,200.00
| Facility | | $2,200.00 | $2,200.00 | $2,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $778.39 / $1,221.35 / $3,369.15
| Professional | | $778.39 | $1,221.35 | $3,369.15 |