- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,864.50 / $20,864.50 / $20,864.50
| Facility | | $20,864.50 | $20,864.50 | $20,864.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20,864.50 / $23,845.15 / $24,070.50
| Professional | | $20,864.50 | $23,845.15 | $24,070.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31,290.51 / $31,290.51 / $31,290.51
| Facility | | $31,290.51 | $31,290.51 | $31,290.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,842.07 / $31,290.51 / $31,290.51
| Professional | | $22,842.07 | $31,290.51 | $31,290.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,917.11 / $29,206.33 / $225,247.51
| Facility | | $13,917.11 | $29,206.33 | $225,247.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,371.62 / $28,486.86 / $47,488.54
| Professional | | $14,371.62 | $28,486.86 | $47,488.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,371.62 / $21,926.67 / $32,473.24
| Professional | | $14,371.62 | $21,926.67 | $32,473.24 |