- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40,881.19 / $40,881.19 / $40,881.19
| Facility | | $40,881.19 | $40,881.19 | $40,881.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20,763.04 / $40,881.19 / $40,881.19
| Professional | | $20,763.04 | $40,881.19 | $40,881.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31,290.51 / $31,290.51 / $48,370.76
| Facility | | $31,290.51 | $31,290.51 | $48,370.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,842.07 / $31,290.51 / $46,289.43
| Professional | | $22,842.07 | $31,290.51 | $46,289.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,371.62 / $24,262.36 / $33,401.19
| Professional | | $14,371.62 | $24,262.36 | $33,401.19 |