- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,821.90 / $27,688.30 / $39,258.19
| Facility | | $15,821.90 | $27,688.30 | $39,258.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,821.90 / $15,821.91 / $15,821.91
| Professional | | $15,821.90 | $15,821.91 | $15,821.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,087.50 / $16,087.50 / $16,087.50
| Professional | | $16,087.50 | $16,087.50 | $16,087.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25,629.86 / $25,629.86 / $25,629.86
| Professional | | $25,629.86 | $25,629.86 | $25,629.86 |