- 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
- $2,001.22 / $2,001.22 / $2,207.96
| Professional | | $2,001.22 | $2,001.22 | $2,207.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,927.35 / $2,250.09 / $3,943.47
| Professional | | $1,927.35 | $2,250.09 | $3,943.47 |
- 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
- $1,876.60 / $2,299.19 / $5,093.58
| Professional | | $1,876.60 | $2,299.19 | $5,093.58 |