- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Professional | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Facility | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $5,128.61 / $8,511.38
| Professional | | $912.01 | $5,128.61 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,128.31 / $10,232.93
| Facility | | $5,128.61 | $8,128.31 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $5,248.07
| Professional | | $79.43 | $79.43 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $851.14 / $5,623.41
| Facility | | $426.58 | $851.14 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,630.78 / $4,168.69
| Professional | | $3,235.94 | $3,630.78 | $4,168.69 |