- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,988.33 / $28,183.83 / $35,481.34
| Facility | | $23,988.33 | $28,183.83 | $35,481.34 |
- 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
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,988.33 / $44,668.36 / $44,668.36
| Facility | | $23,988.33 | $44,668.36 | $44,668.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,988.33 / $23,988.33 / $125,892.54
| Professional | | $23,988.33 | $23,988.33 | $125,892.54 |
- 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 / $24,547.09 / $28,183.83
| Professional | | $23,442.29 | $24,547.09 | $28,183.83 |