- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,500.00 / $34,906.19 / $34,906.19
| Facility | | $4,500.00 | $34,906.19 | $34,906.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34,906.19 / $34,906.19 / $34,906.19
| Professional | | $34,906.19 | $34,906.19 | $34,906.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $78.00
| Professional | | $30.00 | $30.00 | $78.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,275.02 / $44,515.87 / $57,287.30
| Facility | | $23,275.02 | $44,515.87 | $57,287.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,000.00 / $24,599.00 / $65,746.00
| Facility | | $12,000.00 | $24,599.00 | $65,746.00 |