- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,424.10 / $28,424.10 / $32,687.70
| Facility | | $28,424.10 | $28,424.10 | $32,687.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,424.06 / $29,276.78 / $35,530.07
| Professional | | $28,424.06 | $29,276.78 | $35,530.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,815.15 / $26,815.15 / $28,424.06
| Facility | | $26,815.15 | $26,815.15 | $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
- Facility
- Modifier
- Low / Median / High Price
- $2,250.00 / $28,424.06 / $40,859.58
| Facility | | $2,250.00 | $28,424.06 | $40,859.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,424.06 / $30,129.50 / $35,530.08
| Professional | | $28,424.06 | $30,129.50 | $35,530.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,722.81 / $24,363.48 / $52,787.53
| Professional | | $19,722.81 | $24,363.48 | $52,787.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27,014.86 / $39,931.81 / $67,537.14
| Facility | | $27,014.86 | $39,931.81 | $67,537.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34,108.87 / $34,108.87 / $35,530.08
| Professional | | $34,108.87 | $34,108.87 | $35,530.08 |
- 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 |