- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,964.78 / $12,022.64
| Professional | | $10,000.00 | $10,964.78 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.93 / $9,549.93 / $11,220.18
| Professional | | $9,549.93 | $9,549.93 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,148.15 / $7,762.47
| Facility | | $616.60 | $1,148.15 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,025.60 / $8,912.51
| Professional | | $4,265.80 | $6,025.60 | $8,912.51 |