- 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
- $22,390.08 / $23,789.46 / $23,789.46
| Professional | | $22,390.08 | $23,789.46 | $23,789.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,390.08 / $22,390.08 / $22,390.08
| Professional | | $22,390.08 | $22,390.08 | $22,390.08 |
- 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
- $4,053.84 / $23,789.46 / $23,789.46
| Professional | | $4,053.84 | $23,789.46 | $23,789.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,622.26 / $5,395.80 / $25,188.84
| Professional | | $2,622.26 | $5,395.80 | $25,188.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,323.00 / $25,963.40 / $34,331.92
| Professional | | $23,323.00 | $25,963.40 | $34,331.92 |