- 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
- $922.35 / $922.35 / $987.87
| Professional | | $922.35 | $922.35 | $987.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.29 / $1,106.85 / $1,245.44
| Professional | | $806.29 | $1,106.85 | $1,245.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Facility | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.12 / $1,024.58 / $2,149.46
| Professional | | $832.12 | $1,024.58 | $2,149.46 |