- 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
- $1,352.10 / $1,538.23 / $1,538.23
| Professional | | $1,352.10 | $1,538.23 | $1,538.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.10 / $1,617.36 / $2,827.69
| Professional | | $1,357.10 | $1,617.36 | $2,827.69 |
- 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
- $1,291.72 / $1,656.73 / $3,539.32
| Professional | | $1,291.72 | $1,656.73 | $3,539.32 |