- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,126.70 / $14,126.71 / $30,796.25
| Facility | | $14,126.70 | $14,126.71 | $30,796.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,126.71 / $14,126.71 / $14,126.71
| Professional | | $14,126.71 | $14,126.71 | $14,126.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,753.56 / $19,753.56 / $23,704.27
| Facility | | $19,753.56 | $19,753.56 | $23,704.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,622.40 / $23,622.40 / $23,622.40
| Facility | | $23,622.40 | $23,622.40 | $23,622.40 |
- 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 |