- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,819.70 / $1,995.26
| Facility | | $851.14 | $1,819.70 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,488.17 / $15,488.17 / $15,488.17
| Professional | | $15,488.17 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,620.87 / $18,620.87 / $20,417.38
| Facility | | $18,620.87 | $18,620.87 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $7,762.47 / $7,762.47
| Professional | | $7,762.47 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,882.50 / $12,882.50 / $12,882.50
| Facility | | $12,882.50 | $12,882.50 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Professional | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $9,332.54 / $22,908.68
| Facility | | $1,348.96 | $9,332.54 | $22,908.68 |