- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,260.46 / $2,260.46
| Facility | | $1,400.00 | $2,260.46 | $2,260.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.58 / $1,884.50 / $2,260.46
| Professional | | $663.58 | $1,884.50 | $2,260.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,806.76 / $27,420.79 / $56,395.72
| Facility | | $5,806.76 | $27,420.79 | $56,395.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119,998.80 / $119,998.80 / $119,998.80
| Professional | | $119,998.80 | $119,998.80 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,248.48 / $2,248.48 / $2,248.48
| Facility | | $2,248.48 | $2,248.48 | $2,248.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,360.83 / $9,360.83 / $9,360.83
| Professional | | $9,360.83 | $9,360.83 | $9,360.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,910.00 / $2,910.00 / $2,910.00
| Facility | | $2,910.00 | $2,910.00 | $2,910.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.59 / $1,018.43 / $2,937.77
| Professional | | $561.59 | $1,018.43 | $2,937.77 |