- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,391.94 / $8,391.94 / $8,391.94
| Facility | | $8,391.94 | $8,391.94 | $8,391.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $899.52 / $8,391.94 / $11,397.96
| Professional | | $899.52 | $8,391.94 | $11,397.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,104.06 / $7,630.07 / $13,753.60
| Facility | | $6,104.06 | $7,630.07 | $13,753.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $899.52 / $8,391.94 / $11,397.96
| Professional | | $899.52 | $8,391.94 | $11,397.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,224.28 / $4,224.28 / $4,869.43
| Professional | | $4,224.28 | $4,224.28 | $4,869.43 |