- 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
- $711.30 / $726.53 / $726.53
| Professional | | $711.30 | $726.53 | $726.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.04 / $882.75 / $1,258.35
| Professional | | $652.04 | $882.75 | $1,258.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,459.36 / $7,459.36 / $7,459.36
| Facility | | $7,459.36 | $7,459.36 | $7,459.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $625.52 / $809.68 / $1,626.55
| Professional | | $625.52 | $809.68 | $1,626.55 |