- 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
- $1,233.28 / $1,265.66 / $1,265.66
| Professional | | $1,233.28 | $1,265.66 | $1,265.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.46 / $1,552.82 / $2,192.12
| Professional | | $1,083.46 | $1,552.82 | $2,192.12 |
- 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
- $1,037.39 / $1,338.67 / $2,818.61
| Professional | | $1,037.39 | $1,338.67 | $2,818.61 |