- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,424.06 / $28,424.10 / $28,424.10
| Facility | | $28,424.06 | $28,424.10 | $28,424.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,424.06 / $28,424.06 / $34,108.87
| Professional | | $28,424.06 | $28,424.06 | $34,108.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,399.81 / $25,969.67 / $34,937.53
| Facility | | $21,399.81 | $25,969.67 | $34,937.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,424.06 / $28,424.06 / $28,424.06
| Professional | | $28,424.06 | $28,424.06 | $28,424.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,424.06 / $28,424.06 / $28,424.06
| Facility | | $28,424.06 | $28,424.06 | $28,424.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,424.06 / $28,424.06 / $28,424.06
| Professional | | $28,424.06 | $28,424.06 | $28,424.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,739.25 / $28,424.06 / $30,982.23
| Professional | | $22,739.25 | $28,424.06 | $30,982.23 |