- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $42,657.95
| Facility | | $28,183.83 | $28,183.83 | $42,657.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $31,622.78
| Professional | | $28,183.83 | $28,183.83 | $31,622.78 |
- 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
- $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 / $40,738.03 / $40,738.03
| Facility | | $26,915.35 | $40,738.03 | $40,738.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $120,226.44
| Professional | | $28,183.83 | $28,183.83 | $120,226.44 |
- 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
- $28,183.83 / $30,199.52 / $33,113.11
| Professional | | $28,183.83 | $30,199.52 | $33,113.11 |