- 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
- $2,025.00 / $2,293.67 / $2,293.67
| Professional | | $2,025.00 | $2,293.67 | $2,293.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,009.94 / $2,397.92 / $4,138.07
| Professional | | $2,009.94 | $2,397.92 | $4,138.07 |
- 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
- $1,965.53 / $2,511.16 / $5,314.30
| Professional | | $1,965.53 | $2,511.16 | $5,314.30 |