- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,011.87 / $5,248.07
| Professional | | $3,467.37 | $5,011.87 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $9,332.54 / $9,332.54
| Facility | | $9,332.54 | $9,332.54 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,332.54 / $9,332.54 / $9,332.54
| Professional | | $9,332.54 | $9,332.54 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,232.93 / $32,359.37
| Facility | | $10,000.00 | $10,232.93 | $32,359.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,232.93 / $32,359.37
| Professional | | $10,000.00 | $10,232.93 | $32,359.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,466.84 / $9,332.54
| Facility | | $1,548.82 | $4,466.84 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $9,332.54 / $11,220.18
| Professional | | $79.43 | $9,332.54 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,905.46 / $4,168.69
| Professional | | $1,288.25 | $1,905.46 | $4,168.69 |