- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,816.00 / $5,816.00 / $6,907.00
| Facility | | $5,816.00 | $5,816.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.75 / $2,120.54 / $2,120.54
| Professional | | $1,819.75 | $2,120.54 | $2,120.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,786.12 / $2,484.42 / $3,531.51
| Professional | | $1,786.12 | $2,484.42 | $3,531.51 |
- 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
- $1,848.78 / $2,486.19 / $4,519.79
| Professional | | $1,848.78 | $2,486.19 | $4,519.79 |