- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,907.00 / $7,265.00 / $7,899.00
| Facility | | $6,907.00 | $7,265.00 | $7,899.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,702.06 / $1,731.01 / $1,731.01
| Professional | | $1,702.06 | $1,731.01 | $1,731.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,508.44 / $1,960.00 / $3,189.47
| Professional | | $1,508.44 | $1,960.00 | $3,189.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.98 / $2,007.48 / $3,947.43
| Professional | | $1,459.98 | $2,007.48 | $3,947.43 |