- 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
- $1,951.75 / $2,300.06 / $2,300.06
| Professional | | $1,951.75 | $2,300.06 | $2,300.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,929.22 / $2,095.65 / $3,867.14
| Professional | | $1,929.22 | $2,095.65 | $3,867.14 |
- 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
- $1,722.80 / $2,005.93 / $5,287.71
| Professional | | $1,722.80 | $2,005.93 | $5,287.71 |