- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,789.46 / $23,789.50 / $23,789.50
| Facility | | $23,789.46 | $23,789.50 | $23,789.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,390.08 / $23,229.71 / $23,789.46
| Professional | | $22,390.08 | $23,229.71 | $23,789.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $657.13 / $1,536.85 / $48,732.27
| Facility | | $657.13 | $1,536.85 | $48,732.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,323.00 / $23,323.00 / $23,323.00
| Professional | | $23,323.00 | $23,323.00 | $23,323.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,789.46 / $23,789.46 / $23,789.46
| Facility | | $23,789.46 | $23,789.46 | $23,789.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,000.55 / $23,789.46 / $23,789.46
| Professional | | $11,000.55 | $23,789.46 | $23,789.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,824.55 / $23,323.00 / $25,655.30
| Professional | | $19,824.55 | $23,323.00 | $25,655.30 |