- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,261.96 / $1,261.96 / $3,550.00
| Facility | | $1,261.96 | $1,261.96 | $3,550.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.97 / $1,431.27 / $1,600.62
| Professional | | $988.97 | $1,431.27 | $1,600.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,222.60 / $27,819.54 / $55,639.08
| Facility | | $4,222.60 | $27,819.54 | $55,639.08 |
- 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
- $1,923.16 / $1,923.16 / $1,923.16
| Facility | | $1,923.16 | $1,923.16 | $1,923.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.55 / $7,413.55 / $7,413.55
| Professional | | $7,413.55 | $7,413.55 | $7,413.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.70 / $1,783.40 / $2,807.54
| Professional | | $1,057.70 | $1,783.40 | $2,807.54 |