- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $69,162.84 / $69,162.84 / $69,162.84
| Facility | | $69,162.84 | $69,162.84 | $69,162.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65,094.44 / $67,535.48 / $69,162.84
| Professional | | $65,094.44 | $67,535.48 | $69,162.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $63,005.77 / $69,162.84 / $81,536.87
| Facility | | $63,005.77 | $69,162.84 | $81,536.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69,162.84 / $69,162.84 / $69,162.84
| Professional | | $69,162.84 | $69,162.84 | $69,162.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69,162.84 / $69,162.84 / $69,162.84
| Professional | | $69,162.84 | $69,162.84 | $69,162.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,702.00 / $66,537.42 / $133,378.57
| Facility | | $8,702.00 | $66,537.42 | $133,378.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,976.91 / $68,140.74 / $68,140.74
| Professional | | $23,976.91 | $68,140.74 | $68,140.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58,910.18 / $58,910.18 / $58,910.18
| Facility | | $58,910.18 | $58,910.18 | $58,910.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67,806.71 / $67,806.71 / $71,536.08
| Professional | | $67,806.71 | $67,806.71 | $71,536.08 |