- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,899.51 / $6,899.51 / $9,527.89
| Facility | | $6,899.51 | $6,899.51 | $9,527.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,285.48 / $6,516.20 / $6,899.51
| Professional | | $3,285.48 | $6,516.20 | $6,899.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,559.27 / $4,128.75 / $8,186.32
| Facility | | $3,559.27 | $4,128.75 | $8,186.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,928.22 / $4,928.22 / $4,928.22
| Facility | | $4,928.22 | $4,928.22 | $4,928.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.84 / $3,285.48 / $5,475.80
| Professional | | $2,299.84 | $3,285.48 | $5,475.80 |