- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56,234.13 / $56,234.13 / $56,234.13
| Facility | | $56,234.13 | $56,234.13 | $56,234.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $36,307.81
| Professional | | $28,183.83 | $28,183.83 | $36,307.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $30,199.52
| Facility | | $28,183.83 | $28,183.83 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $28,183.83
| Professional | | $28,183.83 | $28,183.83 | $28,183.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,915.35 / $28,183.83 / $28,183.83
| Facility | | $26,915.35 | $28,183.83 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $28,183.83
| Professional | | $28,183.83 | $28,183.83 | $28,183.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $28,183.83
| Facility | | $28,183.83 | $28,183.83 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,915.35 / $28,183.83 / $31,622.78
| Professional | | $26,915.35 | $28,183.83 | $31,622.78 |