- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,789.46 / $27,987.60 / $27,987.60
| Facility | | $23,789.46 | $27,987.60 | $27,987.60 |
- 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
- $1,896.30 / $1,958.06 / $3,426.61
| Facility | | $1,896.30 | $1,958.06 | $3,426.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,896.30 / $1,896.30 / $1,958.06
| Professional | | $1,896.30 | $1,896.30 | $1,958.06 |
- 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
- $23,789.46 / $23,789.46 / $23,789.46
| Professional | | $23,789.46 | $23,789.46 | $23,789.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,323.00 / $25,655.30 / $27,987.60
| Professional | | $23,323.00 | $25,655.30 | $27,987.60 |