- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,943.28 / $7,943.28
| Professional | | $5,495.41 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,079.46
| Facility | | $7,079.46 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $7,079.46 / $8,912.51
| Professional | | $6,025.60 | $7,079.46 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $7,943.28 / $8,912.51
| Facility | | $5,888.44 | $7,943.28 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |