- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,531.66 / $13,531.66 / $13,531.66
| Professional | | $13,531.66 | $13,531.66 | $13,531.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,619.91 / $11,619.91 / $11,619.91
| Facility | | $11,619.91 | $11,619.91 | $11,619.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,876.92 / $9,876.92 / $11,619.91
| Professional | | $9,876.92 | $9,876.92 | $11,619.91 |
- 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
- $698.85 / $698.85 / $698.85
| Professional | | $698.85 | $698.85 | $698.85 |