- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,554.24 / $6,554.24 / $6,554.24
| Professional | | $6,554.24 | $6,554.24 | $6,554.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,694.63 / $10,694.63 / $10,694.63
| Facility | | $10,694.63 | $10,694.63 | $10,694.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.51 / $10,694.63 / $20,182.50
| Professional | | $1,230.51 | $10,694.63 | $20,182.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,940.17 / $6,948.27 / $11,015.55
| Professional | | $3,940.17 | $6,948.27 | $11,015.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,102.02 / $4,922.04 / $9,115.60
| Professional | | $4,102.02 | $4,922.04 | $9,115.60 |