- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $7,762.47 / $10,000.00
| Professional | | $5,370.32 | $7,762.47 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $173.78
| Facility | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Professional | | $6,456.54 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $8,511.38
| Facility | | $5,128.61 | $5,128.61 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $5,128.61 / $14,791.08
| Professional | | $912.01 | $5,128.61 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $1,318.26 / $5,623.41
| Facility | | $354.81 | $1,318.26 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,073.80 / $5,888.44
| Professional | | $2,454.71 | $4,073.80 | $5,888.44 |