- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,399.88 / $1,399.88 / $1,749.84
| Professional | | $1,399.88 | $1,399.88 | $1,749.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83,492.39 / $83,492.39 / $83,492.39
| Facility | | $83,492.39 | $83,492.39 | $83,492.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,317.02 / $4,317.02 / $4,317.02
| Professional | | $4,317.02 | $4,317.02 | $4,317.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,007.38 / $1,492.48 / $30,028.49
| Facility | | $1,007.38 | $1,492.48 | $30,028.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.38 / $1,251.89 / $1,492.48
| Professional | | $1,007.38 | $1,251.89 | $1,492.48 |