- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Professional | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,981.07
| Professional | | $3,715.35 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,888.44 / $10,000.00
| Facility | | $5,011.87 | $5,888.44 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $891.25
| Facility | | $354.81 | $354.81 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $912.01
| Professional | | $891.25 | $891.25 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |