- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,447.14 / $7,447.14 / $7,447.14
| Facility | | $7,447.14 | $7,447.14 | $7,447.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.86 / $7,447.14 / $8,054.04
| Professional | | $856.86 | $7,447.14 | $8,054.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,466.03 / $7,482.56 / $9,718.56
| Facility | | $6,466.03 | $7,482.56 | $9,718.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.86 / $7,447.14 / $8,054.04
| Professional | | $856.86 | $7,447.14 | $8,054.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,097.80 / $3,427.44 / $5,712.40
| Professional | | $3,097.80 | $3,427.44 | $5,712.40 |