- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,239.88 / $2,239.88 / $2,799.84
| Professional | | $2,239.88 | $2,239.88 | $2,799.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65,302.40 / $65,302.40 / $65,302.40
| Facility | | $65,302.40 | $65,302.40 | $65,302.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,504.72 / $5,504.72 / $5,504.72
| Professional | | $5,504.72 | $5,504.72 | $5,504.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,363.16 / $1,694.03 / $23,486.93
| Facility | | $1,363.16 | $1,694.03 | $23,486.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,363.16 / $1,388.68 / $1,694.03
| Professional | | $1,363.16 | $1,388.68 | $1,694.03 |