- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $6,918.31
| Professional | | $6,918.31 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $9,120.11
| Professional | | $7,244.36 | $7,244.36 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $8,317.64
| Facility | | $6,918.31 | $6,918.31 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $6,918.31
| Professional | | $6,918.31 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $2,630.27 / $4,677.35
| Professional | | $30.20 | $2,630.27 | $4,677.35 |