- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,663.50 / $1,663.50 / $1,663.50
| Professional | | $1,663.50 | $1,663.50 | $1,663.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,996.00 / $3,996.00 / $3,996.00
| Facility | | $3,996.00 | $3,996.00 | $3,996.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,915.00 / $3,996.00 / $4,893.75
| Professional | | $3,915.00 | $3,996.00 | $4,893.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $99,999.99 / $99,999.99 / $99,999.99
| Facility | | $99,999.99 | $99,999.99 | $99,999.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,432.37 / $3,914.10 / $99,999.99
| Professional | | $3,432.37 | $3,914.10 | $99,999.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.80 / $1,565.64 / $2,876.84
| Professional | | $1,330.80 | $1,565.64 | $2,876.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,473.99 / $3,473.99 / $3,473.99
| Professional | | $3,473.99 | $3,473.99 | $3,473.99 |