- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,316.00 / $6,316.00 / $6,907.00
| Facility | | $6,316.00 | $6,316.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.47 / $1,104.57 / $1,104.57
| Professional | | $1,075.47 | $1,104.57 | $1,104.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.94 / $1,291.41 / $2,035.24
| Professional | | $925.94 | $1,291.41 | $2,035.24 |
- 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
- $856.38 / $1,131.38 / $2,405.28
| Professional | | $856.38 | $1,131.38 | $2,405.28 |