- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,288.25
| Professional | | $1,202.26 | $1,202.26 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,090.30
| Professional | | $2,454.71 | $2,454.71 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Facility | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,022.64 / $12,302.69 / $12,302.69
| Professional | | $12,022.64 | $12,302.69 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,071.52 / $1,230.27
| Facility | | $616.60 | $1,071.52 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $794.33 / $1,202.26
| Professional | | $524.81 | $794.33 | $1,202.26 |