- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,972.65 / $21,972.65 / $34,332.26
| Facility | | $21,972.65 | $21,972.65 | $34,332.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,972.65 / $34,332.26 / $39,949.44
| Professional | | $21,972.65 | $34,332.26 | $39,949.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30,383.51 / $30,383.51 / $30,383.51
| Facility | | $30,383.51 | $30,383.51 | $30,383.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30,383.51 / $30,383.51 / $30,383.51
| Professional | | $30,383.51 | $30,383.51 | $30,383.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30,391.12 / $30,391.12 / $30,391.12
| Facility | | $30,391.12 | $30,391.12 | $30,391.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,185.52 / $22,185.52 / $30,391.12
| Professional | | $22,185.52 | $22,185.52 | $30,391.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,040.44 / $19,560.65 / $30,142.37
| Professional | | $13,040.44 | $19,560.65 | $30,142.37 |