- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66,069.34 / $70,794.58 / $70,794.58
| Facility | | $66,069.34 | $70,794.58 | $70,794.58 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $27,542.29 / $33,113.11 / $89,125.09
| Facility | | $27,542.29 | $33,113.11 | $89,125.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $29,512.09
| Professional | | $28,183.83 | $28,183.83 | $29,512.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $40,738.03
| Facility | | $28,183.83 | $28,183.83 | $40,738.03 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $28,840.32
| Professional | | $28,183.83 | $28,183.83 | $28,840.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66,069.34 / $66,069.34 / $70,794.58
| Facility | | $66,069.34 | $66,069.34 | $70,794.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $29,512.09 / $42,657.95
| Professional | | $28,183.83 | $29,512.09 | $42,657.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,988.33 / $28,183.83 / $33,884.42
| Professional | | $23,988.33 | $28,183.83 | $33,884.42 |