- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,072.81 / $8,072.81 / $8,072.81
| Facility | | $8,072.81 | $8,072.81 | $8,072.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.85 / $8,072.81 / $8,730.71
| Professional | | $928.85 | $8,072.81 | $8,730.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,009.23 / $8,327.36 / $10,535.04
| Facility | | $7,009.23 | $8,327.36 | $10,535.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.85 / $8,072.81 / $8,730.71
| Professional | | $928.85 | $8,072.81 | $8,730.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,358.02 / $3,715.40 / $6,192.33
| Professional | | $3,358.02 | $3,715.40 | $6,192.33 |