- 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
- $1,044.81 / $1,099.02 / $1,099.02
| Professional | | $1,044.81 | $1,099.02 | $1,099.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.66 / $1,197.22 / $2,083.19
| Professional | | $1,009.66 | $1,197.22 | $2,083.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,170.00 / $5,170.00 / $5,170.00
| Facility | | $5,170.00 | $5,170.00 | $5,170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $934.38 / $1,093.97 / $2,623.48
| Professional | | $934.38 | $1,093.97 | $2,623.48 |