- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,328.69 / $16,328.69 / $25,513.58
| Facility | | $16,328.69 | $16,328.69 | $25,513.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,327.77 / $23,740.31 / $25,513.58
| Professional | | $15,327.77 | $23,740.31 | $25,513.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27,733.26 / $27,733.26 / $27,733.26
| Facility | | $27,733.26 | $27,733.26 | $27,733.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27,733.26 / $27,733.26 / $27,733.26
| Professional | | $27,733.26 | $27,733.26 | $27,733.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,200.25 / $16,200.25 / $16,200.25
| Facility | | $16,200.25 | $16,200.25 | $16,200.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,826.18 / $11,826.18 / $16,200.25
| Professional | | $11,826.18 | $11,826.18 | $16,200.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29,383.10 / $34,568.35 / $41,482.01
| Facility | | $29,383.10 | $34,568.35 | $41,482.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,622.87 / $14,536.25 / $19,931.41
| Professional | | $8,622.87 | $14,536.25 | $19,931.41 |