- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,316.00 / $6,316.00 / $6,907.00
| Facility | | $6,316.00 | $6,316.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.65 / $1,552.37 / $1,674.36
| Professional | | $1,165.65 | $1,552.37 | $1,674.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $899.00 / $899.00 / $899.00
| Facility | | $899.00 | $899.00 | $899.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.97 / $1,112.74 / $1,701.05
| Professional | | $1,053.97 | $1,112.74 | $1,701.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.85 / $1,241.53 / $2,956.71
| Professional | | $1,003.85 | $1,241.53 | $2,956.71 |