- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,835.00 / $6,835.00 / $6,907.00
| Facility | | $6,835.00 | $6,835.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,655.78 / $1,952.93 / $1,952.93
| Professional | | $1,655.78 | $1,952.93 | $1,952.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,715.43 / $2,096.17 / $3,612.37
| Professional | | $1,715.43 | $2,096.17 | $3,612.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,170.00 / $5,170.00 / $5,170.00
| Facility | | $5,170.00 | $5,170.00 | $5,170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.29 / $1,942.61 / $4,472.20
| Professional | | $1,611.29 | $1,942.61 | $4,472.20 |