- 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
- $1,953.11 / $2,299.81 / $2,299.81
| Professional | | $1,953.11 | $2,299.81 | $2,299.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,013.45 / $2,106.63 / $3,834.05
| Professional | | $2,013.45 | $2,106.63 | $3,834.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,000.00 / $3,000.00 / $5,170.00
| Facility | | $3,000.00 | $3,000.00 | $5,170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,745.23 / $2,153.06 / $5,302.05
| Professional | | $1,745.23 | $2,153.06 | $5,302.05 |