- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,424.10 / $30,698.00 / $43,281.10
| Facility | | $28,424.10 | $30,698.00 | $43,281.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,424.06 / $28,992.54 / $34,393.10
| Professional | | $28,424.06 | $28,992.54 | $34,393.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,252.85 / $6,708.92 / $10,637.68
| Facility | | $4,252.85 | $6,708.92 | $10,637.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,815.15 / $26,815.15 / $28,424.06
| Facility | | $26,815.15 | $26,815.15 | $28,424.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,424.06 / $28,424.06 / $28,424.06
| Professional | | $28,424.06 | $28,424.06 | $28,424.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,566.89 / $30,697.98 / $41,214.89
| Facility | | $17,566.89 | $30,697.98 | $41,214.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25,781.46 / $28,424.06 / $119,518.82
| Professional | | $25,781.46 | $28,424.06 | $119,518.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,424.06 / $28,424.06 / $33,824.62
| Professional | | $28,424.06 | $28,424.06 | $33,824.62 |