- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,760.83 / $10,000.00
| Professional | | $3,890.45 | $6,760.83 | $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
- $4,365.16 / $5,128.61 / $14,791.08
| Professional | | $4,365.16 | $5,128.61 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $8,511.38 / $8,511.38
| Professional | | $5,754.40 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $1,318.26 / $8,709.64
| Facility | | $407.38 | $1,318.26 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,265.80 / $8,317.64
| Professional | | $2,818.38 | $4,265.80 | $8,317.64 |