- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,879.80 / $5,879.80 / $5,879.80
| Professional | | $5,879.80 | $5,879.80 | $5,879.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,587.41 / $10,587.41 / $10,587.41
| Facility | | $10,587.41 | $10,587.41 | $10,587.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.81 / $1,092.81 / $10,649.82
| Professional | | $1,092.81 | $1,092.81 | $10,649.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.68 / $273.68 / $273.68
| Professional | | $273.68 | $273.68 | $273.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,762.00 / $9,584.84 / $10,845.65
| Professional | | $5,762.00 | $9,584.84 | $10,845.65 |