- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,943.28
| Facility | | $7,079.46 | $7,079.46 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $7,943.28 / $7,943.28
| Professional | | $3,801.89 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,943.28 / $12,022.64
| Facility | | $7,079.46 | $7,943.28 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $7,943.28 / $7,943.28
| Professional | | $3,801.89 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,943.28 / $11,481.54
| Facility | | $7,079.46 | $7,943.28 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $79.43 / $79.43
| Professional | | $60.26 | $79.43 | $79.43 |