- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,523.10 / $6,523.10 / $6,523.10
| Professional | | $6,523.10 | $6,523.10 | $6,523.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,718.36 / $9,718.36 / $11,551.88
| Facility | | $9,718.36 | $9,718.36 | $11,551.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,718.36 / $9,718.36 / $9,718.36
| Professional | | $9,718.36 | $9,718.36 | $9,718.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,718.36 / $9,718.36 / $11,551.88
| Facility | | $9,718.36 | $9,718.36 | $11,551.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.09 / $9,718.36 / $13,447.34
| Professional | | $820.09 | $9,718.36 | $13,447.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,801.22 / $17,413.80 / $26,369.69
| Professional | | $14,801.22 | $17,413.80 | $26,369.69 |