- 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
- $1,099.22 / $1,121.14 / $1,278.57
| Professional | | $1,099.22 | $1,121.14 | $1,278.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.06 / $1,338.66 / $2,332.98
| Professional | | $1,127.06 | $1,338.66 | $2,332.98 |
- 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
- $1,080.94 / $1,350.57 / $2,922.60
| Professional | | $1,080.94 | $1,350.57 | $2,922.60 |