- 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 / $33,113.11
| Professional | | $28,183.83 | $28,183.83 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,840.32 / $33,884.42 / $33,884.42
| Professional | | $28,840.32 | $33,884.42 | $33,884.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,915.35 / $26,915.35 / $26,915.35
| Facility | | $26,915.35 | $26,915.35 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $39,810.72
| Professional | | $28,183.83 | $28,183.83 | $39,810.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $53,703.18
| Facility | | $28,183.83 | $28,183.83 | $53,703.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,915.35 / $28,183.83 / $30,199.52
| Professional | | $26,915.35 | $28,183.83 | $30,199.52 |