- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44,668.36 / $44,668.36 / $44,668.36
| Facility | | $44,668.36 | $44,668.36 | $44,668.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,387.21 / $23,442.29 / $28,183.83
| Professional | | $22,387.21 | $23,442.29 | $28,183.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,547.09 / $24,547.09 / $26,302.68
| Facility | | $24,547.09 | $24,547.09 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25,118.86 / $25,118.86 / $25,118.86
| Professional | | $25,118.86 | $25,118.86 | $25,118.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,988.33 / $23,988.33 / $23,988.33
| Facility | | $23,988.33 | $23,988.33 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,988.33 / $23,988.33 / $23,988.33
| Professional | | $23,988.33 | $23,988.33 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,988.33 / $23,988.33 / $23,988.33
| Facility | | $23,988.33 | $23,988.33 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,442.29 / $23,442.29 / $25,703.96
| Professional | | $23,442.29 | $23,442.29 | $25,703.96 |