- 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
- $1,282.90 / $1,363.68 / $1,363.68
| Professional | | $1,282.90 | $1,363.68 | $1,363.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.22 / $1,486.51 / $2,602.55
| Professional | | $1,251.22 | $1,486.51 | $2,602.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $960.00 / $960.00
| Facility | | $960.00 | $960.00 | $960.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.45 / $1,342.69 / $3,166.74
| Professional | | $1,158.45 | $1,342.69 | $3,166.74 |