- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $16,218.10
| Facility | | $16,218.10 | $16,218.10 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $1,258.93 / $25,118.86
| Professional | | $338.84 | $1,258.93 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,000.00 / $1,258.93
| Professional | | $977.24 | $1,000.00 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,000.00 / $1,000.00
| Facility | | $812.83 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |