- 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
- $1,574.25 / $1,818.67 / $1,818.67
| Professional | | $1,574.25 | $1,818.67 | $1,818.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,597.53 / $1,939.56 / $3,372.51
| Professional | | $1,597.53 | $1,939.56 | $3,372.51 |
- 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
- $1,555.27 / $1,956.72 / $4,205.07
| Professional | | $1,555.27 | $1,956.72 | $4,205.07 |