- 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
- $2,741.66 / $2,911.84 / $2,911.84
| Professional | | $2,741.66 | $2,911.84 | $2,911.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,666.38 / $3,049.21 / $5,591.36
| Professional | | $2,666.38 | $3,049.21 | $5,591.36 |
- 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
- $2,538.94 / $3,017.34 / $6,955.28
| Professional | | $2,538.94 | $3,017.34 | $6,955.28 |