- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,265.49 / $1,265.49 / $1,600.00
| Facility | | $1,265.49 | $1,265.49 | $1,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.13 / $1,265.49 / $1,388.44
| Professional | | $975.13 | $1,265.49 | $1,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,704.12 / $20,825.54 / $42,829.61
| Facility | | $4,704.12 | $20,825.54 | $42,829.61 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $1,117.04 / $1,605.75 / $2,619.51
| Professional | | $1,117.04 | $1,605.75 | $2,619.51 |