- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,816.00 / $5,816.00 / $6,907.00
| Facility | | $5,816.00 | $5,816.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.46 / $1,056.22 / $1,056.22
| Professional | | $1,002.46 | $1,056.22 | $1,056.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,296.41 / $4,296.41 / $4,296.41
| Facility | | $4,296.41 | $4,296.41 | $4,296.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.64 / $1,169.21 / $2,074.80
| Professional | | $943.64 | $1,169.21 | $2,074.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,530.00 / $2,530.00 / $2,530.00
| Facility | | $2,530.00 | $2,530.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.53 / $1,129.71 / $2,475.36
| Professional | | $915.53 | $1,129.71 | $2,475.36 |