- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,191.44 / $6,191.44 / $6,191.44
| Professional | | $6,191.44 | $6,191.44 | $6,191.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,102.62 / $10,102.62 / $10,102.62
| Facility | | $10,102.62 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.40 / $10,102.62 / $19,068.75
| Professional | | $1,162.40 | $10,102.62 | $19,068.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,722.06 / $6,563.63 / $10,405.75
| Professional | | $3,722.06 | $6,563.63 | $10,405.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,836.39 / $4,649.60 / $8,525.29
| Professional | | $3,836.39 | $4,649.60 | $8,525.29 |