- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,307.07 / $10,307.07 / $10,307.07
| Professional | | $10,307.07 | $10,307.07 | $10,307.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,562.44 / $5,562.44 / $5,562.44
| Facility | | $5,562.44 | $5,562.44 | $5,562.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,562.44 / $5,562.44 / $5,562.44
| Professional | | $5,562.44 | $5,562.44 | $5,562.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,562.44 / $5,562.44 / $5,562.44
| Facility | | $5,562.44 | $5,562.44 | $5,562.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,562.44 / $20,102.59 / $21,248.54
| Professional | | $5,562.44 | $20,102.59 | $21,248.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,498.82 / $16,945.38 / $20,104.72
| Professional | | $13,498.82 | $16,945.38 | $20,104.72 |