- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,874.59 / $7,874.59 / $7,874.59
| Professional | | $7,874.59 | $7,874.59 | $7,874.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,100.47 / $7,100.47 / $7,100.47
| Facility | | $7,100.47 | $7,100.47 | $7,100.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,035.40 / $7,100.47 / $7,100.47
| Professional | | $6,035.40 | $7,100.47 | $7,100.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $200.00
| Professional | | $100.00 | $100.00 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.71 / $527.71 / $527.71
| Professional | | $527.71 | $527.71 | $527.71 |