- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,183.83 / $45,708.82 / $79,432.82
| Facility | | $28,183.83 | $45,708.82 | $79,432.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $35,481.34
| Professional | | $28,183.83 | $28,183.83 | $35,481.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30,199.52 / $38,904.51 / $85,113.80
| Facility | | $30,199.52 | $38,904.51 | $85,113.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $38,018.94
| Professional | | $28,183.83 | $28,183.83 | $38,018.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,915.35 / $28,183.83 / $40,738.03
| Facility | | $26,915.35 | $28,183.83 | $40,738.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $33,113.11
| Professional | | $28,183.83 | $28,183.83 | $33,113.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,915.35 / $28,183.83 / $47,863.01
| Facility | | $26,915.35 | $28,183.83 | $47,863.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,915.35 / $28,183.83 / $32,359.37
| Professional | | $26,915.35 | $28,183.83 | $32,359.37 |