- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40,738.03 / $40,738.03 / $40,738.03
| Facility | | $40,738.03 | $40,738.03 | $40,738.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $29,512.09
| Professional | | $28,183.83 | $28,183.83 | $29,512.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $28,183.83
| Facility | | $28,183.83 | $28,183.83 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $28,183.83
| Professional | | $28,183.83 | $28,183.83 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $30,199.52 / $32,359.37
| Professional | | $28,183.83 | $30,199.52 | $32,359.37 |