- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,816.00 / $5,816.00 / $6,907.00
| Facility | | $5,816.00 | $5,816.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.73 / $1,112.23 / $1,112.23
| Professional | | $974.73 | $1,112.23 | $1,112.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.56 / $1,154.53 / $2,039.93
| Professional | | $980.56 | $1,154.53 | $2,039.93 |
- 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
- $939.42 / $1,201.14 / $2,539.96
| Professional | | $939.42 | $1,201.14 | $2,539.96 |