- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,647.67 / $6,647.67 / $6,647.67
| Facility | | $6,647.67 | $6,647.67 | $6,647.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,376.27 / $6,647.67 / $6,647.67
| Professional | | $3,376.27 | $6,647.67 | $6,647.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,391.66 / $4,391.66 / $7,865.54
| Facility | | $4,391.66 | $4,391.66 | $7,865.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,732.91 / $4,391.66 / $7,527.11
| Professional | | $3,732.91 | $4,391.66 | $7,527.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,337.54 / $3,945.29 / $5,431.35
| Professional | | $2,337.54 | $3,945.29 | $5,431.35 |