- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,481.54 / $11,481.54 / $11,481.54
| Professional | | $11,481.54 | $11,481.54 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,318.26 / $1,995.26
| Facility | | $416.87 | $1,318.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,000.00 / $2,884.03
| Professional | | $891.25 | $1,000.00 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,630.78 / $5,888.44
| Facility | | $2,041.74 | $3,630.78 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,630.78 / $12,022.64
| Facility | | $2,137.96 | $3,630.78 | $12,022.64 |