- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,110.14 / $22,110.14 / $22,110.14
| Facility | | $22,110.14 | $22,110.14 | $22,110.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20,668.97 / $22,110.14 / $33,195.05
| Professional | | $20,668.97 | $22,110.14 | $33,195.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39,482.40 / $44,362.42 / $80,544.10
| Facility | | $39,482.40 | $44,362.42 | $80,544.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.59 / $27,204.15 / $54,000.00
| Professional | | $1,905.59 | $27,204.15 | $54,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31,019.05 / $31,019.05 / $44,937.75
| Professional | | $31,019.05 | $31,019.05 | $44,937.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,110.14 / $27,706.21 / $39,482.40
| Facility | | $22,110.14 | $27,706.21 | $39,482.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27,706.21 / $27,706.21 / $27,706.21
| Professional | | $27,706.21 | $27,706.21 | $27,706.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,822.15 / $45,404.76 / $78,175.14
| Professional | | $28,822.15 | $45,404.76 | $78,175.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,874.21 / $19,874.21 / $33,123.69
| Professional | | $19,874.21 | $19,874.21 | $33,123.69 |