- 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
- $2,482.81 / $2,637.18 / $2,637.18
| Professional | | $2,482.81 | $2,637.18 | $2,637.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,416.09 / $2,799.74 / $5,106.72
| Professional | | $2,416.09 | $2,799.74 | $5,106.72 |
- 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
- $2,324.35 / $3,029.88 / $6,284.47
| Professional | | $2,324.35 | $3,029.88 | $6,284.47 |