- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,106.50 / $1,106.50 / $14,093.10
| Professional | | $1,106.50 | $1,106.50 | $14,093.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $748.16 / $856.90 / $933.61
| Facility | | $748.16 | $856.90 | $933.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $829.87 / $829.87 / $829.87
| Professional | | $829.87 | $829.87 | $829.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50,344.63 / $50,344.63 / $50,344.63
| Facility | | $50,344.63 | $50,344.63 | $50,344.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,302.54 / $16,482.24 / $28,974.29
| Professional | | $10,302.54 | $16,482.24 | $28,974.29 |