- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,387.21 / $61,659.50 / $69,183.10
| Facility | | $22,387.21 | $61,659.50 | $69,183.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,387.21 / $22,908.68 / $26,915.35
| Professional | | $22,387.21 | $22,908.68 | $26,915.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,908.68 / $47,863.01 / $100,000.00
| Facility | | $22,908.68 | $47,863.01 | $100,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,877.62 / $22,908.68 / $23,988.33
| Professional | | $21,877.62 | $22,908.68 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,988.33 / $23,988.33 / $23,988.33
| Professional | | $23,988.33 | $23,988.33 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,118.86 / $61,659.50 / $77,624.71
| Facility | | $25,118.86 | $61,659.50 | $77,624.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,387.21 / $23,988.33 / $38,904.51
| Professional | | $22,387.21 | $23,988.33 | $38,904.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,988.33 / $23,988.33 / $23,988.33
| Professional | | $23,988.33 | $23,988.33 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,988.33 / $23,988.33 / $23,988.33
| Facility | | $23,988.33 | $23,988.33 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,442.29 / $24,547.09 / $28,183.83
| Professional | | $23,442.29 | $24,547.09 | $28,183.83 |