- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $912.01 / $9,772.37
| Facility | | $645.65 | $912.01 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,748.98 / $13,803.84 / $16,218.10
| Professional | | $11,748.98 | $13,803.84 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $21,379.62 / $21,379.62
| Facility | | $56.23 | $21,379.62 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,840.32 / $28,840.32 / $28,840.32
| Professional | | $28,840.32 | $28,840.32 | $28,840.32 |