- 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
- $2,443.12 / $2,443.12 / $2,443.12
| Professional | | $2,443.12 | $2,443.12 | $2,443.12 |
- 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
- $63,100.60 / $63,100.60 / $63,100.60
| Facility | | $63,100.60 | $63,100.60 | $63,100.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.58 / $1,012.58 / $2,443.12
| Professional | | $1,012.58 | $1,012.58 | $2,443.12 |