- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,399.57 / $11,399.57 / $11,399.57
| Professional | | $11,399.57 | $11,399.57 | $11,399.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $438.60 / $1,640.88 / $2,700.74
| Facility | | $438.60 | $1,640.88 | $2,700.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.64 / $896.86 / $1,121.07
| Professional | | $672.64 | $896.86 | $1,121.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,047.00 / $3,638.00 / $5,133.00
| Facility | | $2,047.00 | $3,638.00 | $5,133.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,140.00 / $3,339.00 / $5,838.00
| Facility | | $2,140.00 | $3,339.00 | $5,838.00 |