- 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 / $11,619.91 / $11,619.91
| Professional | | $9,876.92 | $11,619.91 | $11,619.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,997.66 / $13,531.66 / $15,290.78
| Facility | | $8,997.66 | $13,531.66 | $15,290.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.00 / $100.00 / $100.00
| Facility | | $80.00 | $100.00 | $100.00 |