- 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
- $1,565.78 / $1,665.21 / $1,665.21
| Professional | | $1,565.78 | $1,665.21 | $1,665.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.09 / $1,743.57 / $3,175.77
| Professional | | $1,528.09 | $1,743.57 | $3,175.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $960.00
| Facility | | $150.00 | $150.00 | $960.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.36 / $1,656.92 / $3,941.25
| Professional | | $1,428.36 | $1,656.92 | $3,941.25 |