- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $10,471.29 / $15,848.93
| Professional | | $6,918.31 | $10,471.29 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Facility | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $10,000.00 / $10,000.00
| Professional | | $8,511.38 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $912.01 / $6,165.95
| Facility | | $812.83 | $912.01 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,897.79 / $9,120.11
| Professional | | $3,630.78 | $4,897.79 | $9,120.11 |