- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,608.68 / $7,608.68 / $7,608.68
| Facility | | $7,608.68 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.92 / $7,608.68 / $7,612.44
| Professional | | $816.92 | $7,608.68 | $7,612.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $431.37 / $1,063.65 / $9,185.60
| Facility | | $431.37 | $1,063.65 | $9,185.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.92 / $7,608.68 / $7,612.44
| Professional | | $816.92 | $7,608.68 | $7,612.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,927.94 / $3,357.32 / $5,595.53
| Professional | | $2,927.94 | $3,357.32 | $5,595.53 |