- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $6,918.31
| Professional | | $6,918.31 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $9,332.54 / $100,000.00
| Facility | | $2,238.72 | $9,332.54 | $100,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,238.72 / $69,183.10
| Professional | | $1,479.11 | $2,238.72 | $69,183.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $6,918.31
| Facility | | $6,918.31 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $6,918.31
| Professional | | $6,918.31 | $6,918.31 | $6,918.31 |