- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,316.00 / $6,316.00 / $6,907.00
| Facility | | $6,316.00 | $6,316.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.51 / $1,334.50 / $1,334.50
| Professional | | $1,151.51 | $1,334.50 | $1,334.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.24 / $1,477.97 / $2,555.73
| Professional | | $1,214.24 | $1,477.97 | $2,555.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,783.00 / $2,783.00 / $2,783.00
| Facility | | $2,783.00 | $2,783.00 | $2,783.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.22 / $1,430.63 / $3,188.31
| Professional | | $1,179.22 | $1,430.63 | $3,188.31 |