- 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
- $1,787.20 / $2,029.95 / $2,029.95
| Professional | | $1,787.20 | $2,029.95 | $2,029.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,746.00 / $2,157.81 / $3,662.28
| Professional | | $1,746.00 | $2,157.81 | $3,662.28 |
- 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
- $1,704.68 / $2,054.63 / $4,685.25
| Professional | | $1,704.68 | $2,054.63 | $4,685.25 |