- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,247.09 / $1,247.09 / $2,600.00
| Facility | | $1,247.09 | $1,247.09 | $2,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.08 / $1,318.17 / $1,369.52
| Professional | | $1,181.08 | $1,318.17 | $1,369.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,688.88 / $17,419.68 / $35,826.83
| Facility | | $3,688.88 | $17,419.68 | $35,826.83 |
- 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
- $1,493.35 / $1,493.35 / $1,493.35
| Facility | | $1,493.35 | $1,493.35 | $1,493.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,843.53 / $5,843.53 / $5,843.53
| Professional | | $5,843.53 | $5,843.53 | $5,843.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.41 / $1,827.71 / $2,750.48
| Professional | | $1,044.41 | $1,827.71 | $2,750.48 |