- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,080.00 / $16,979.00 / $28,532.80
| Facility | | $12,080.00 | $16,979.00 | $28,532.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,704.20 / $3,704.20 / $3,704.20
| Professional | | $3,704.20 | $3,704.20 | $3,704.20 |
- 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
- $21,442.45 / $21,442.45 / $21,442.45
| Facility | | $21,442.45 | $21,442.45 | $21,442.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,534.70 / $1,534.70 / $3,704.20
| Professional | | $1,534.70 | $1,534.70 | $3,704.20 |