- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,898.75 / $6,898.75 / $9,526.85
| Facility | | $6,898.75 | $6,898.75 | $9,526.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,285.12 / $6,515.49 / $6,898.75
| Professional | | $3,285.12 | $6,515.49 | $6,898.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,558.88 / $4,128.30 / $9,822.51
| Facility | | $3,558.88 | $4,128.30 | $9,822.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,927.68 / $4,927.68 / $4,927.68
| Facility | | $4,927.68 | $4,927.68 | $4,927.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.58 / $3,285.12 / $5,475.20
| Professional | | $2,299.58 | $3,285.12 | $5,475.20 |