- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34,819.19 / $34,819.19 / $34,819.19
| Facility | | $34,819.19 | $34,819.19 | $34,819.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,475.41 / $34,819.19 / $34,819.19
| Professional | | $19,475.41 | $34,819.19 | $34,819.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38,762.62 / $38,762.62 / $38,762.62
| Facility | | $38,762.62 | $38,762.62 | $38,762.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31,019.05 / $31,019.05 / $44,937.75
| Professional | | $31,019.05 | $31,019.05 | $44,937.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,249.48 / $19,874.21 / $33,123.69
| Professional | | $13,249.48 | $19,874.21 | $33,123.69 |