- 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
- $2,224.71 / $2,224.71 / $2,224.71
| Professional | | $2,224.71 | $2,224.71 | $2,224.71 |
- 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
- $140,989.54 / $140,989.54 / $140,989.54
| Facility | | $140,989.54 | $140,989.54 | $140,989.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.87 / $922.87 / $2,224.71
| Professional | | $922.87 | $922.87 | $2,224.71 |