- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,907.00 / $6,907.00 / $6,907.00
| Facility | | $6,907.00 | $6,907.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,274.52 / $2,274.52 / $2,381.69
| Professional | | $2,274.52 | $2,274.52 | $2,381.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,880.30 / $1,901.94 / $5,854.01
| Professional | | $1,880.30 | $1,901.94 | $5,854.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,092.24 / $5,092.24 / $5,092.24
| Professional | | $5,092.24 | $5,092.24 | $5,092.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,309.07 / $1,915.45 / $5,501.01
| Professional | | $1,309.07 | $1,915.45 | $5,501.01 |