- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $2,137.96 / $2,951.21
| Professional | | $478.63 | $2,137.96 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,897.79 / $10,000.00
| Professional | | $3,981.07 | $4,897.79 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Facility | | $6,309.57 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $3,162.28
| Professional | | $1,318.26 | $1,318.26 | $3,162.28 |