- 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
- $1,786.13 / $2,114.48 / $2,114.48
| Professional | | $1,786.13 | $2,114.48 | $2,114.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.16 / $2,004.31 / $3,745.30
| Professional | | $1,630.16 | $2,004.31 | $3,745.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,530.00
| Facility | | $2,000.00 | $2,000.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.31 / $1,911.78 / $4,771.39
| Professional | | $1,548.31 | $1,911.78 | $4,771.39 |