- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $4,570.88
| Professional | | $4,570.88 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $389.05 / $630.96
| Facility | | $389.05 | $389.05 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $218.78 / $218.78
| Professional | | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $10,000.00 / $10,964.78
| Facility | | $100.00 | $10,000.00 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $10,000.00 / $10,964.78
| Professional | | $100.00 | $10,000.00 | $10,964.78 |