- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,606.93 / $10,000.00
| Professional | | $4,365.16 | $6,606.93 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,801.89 / $3,890.45
| Professional | | $3,235.94 | $3,801.89 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $588.84 / $3,890.45
| Facility | | $512.86 | $588.84 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,162.28 / $5,754.40
| Professional | | $2,290.87 | $3,162.28 | $5,754.40 |