- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,390.08 / $22,390.08 / $42,821.00
| Facility | | $22,390.08 | $22,390.08 | $42,821.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,390.08 / $23,229.71 / $27,987.60
| Professional | | $22,390.08 | $23,229.71 | $27,987.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,489.15 / $24,611.60 / $24,927.51
| Facility | | $24,489.15 | $24,611.60 | $24,927.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20,888.63 / $24,611.60 / $24,927.51
| Professional | | $20,888.63 | $24,611.60 | $24,927.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,192.00 / $3,990.00 / $23,789.46
| Professional | | $3,192.00 | $3,990.00 | $23,789.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,299.84 / $22,390.08 / $29,107.10
| Facility | | $3,299.84 | $22,390.08 | $29,107.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,323.00 / $25,963.40 / $103,405.50
| Professional | | $23,323.00 | $25,963.40 | $103,405.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,323.00 / $23,323.00 / $28,197.55
| Professional | | $23,323.00 | $23,323.00 | $28,197.55 |