- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,539.60 / $6,539.60 / $6,539.60
| Facility | | $6,539.60 | $6,539.60 | $6,539.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.44 / $6,539.60 / $7,072.44
| Professional | | $752.44 | $6,539.60 | $7,072.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,678.03 / $6,570.13 / $8,534.08
| Facility | | $5,678.03 | $6,570.13 | $8,534.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.44 / $6,539.60 / $7,072.44
| Professional | | $752.44 | $6,539.60 | $7,072.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,720.22 / $3,009.76 / $5,016.27
| Professional | | $2,720.22 | $3,009.76 | $5,016.27 |