- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,123.00 / $17,925.00 / $25,614.00
| Facility | | $13,123.00 | $17,925.00 | $25,614.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.89 / $983.89 / $983.89
| Professional | | $983.89 | $983.89 | $983.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $58.40 / $70.00
| Professional | | $50.00 | $58.40 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145,677.60 / $145,677.60 / $145,677.60
| Facility | | $145,677.60 | $145,677.60 | $145,677.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.62 / $575.62 / $983.89
| Professional | | $575.62 | $575.62 | $983.89 |