- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,908.68 / $22,908.68 / $22,908.68
| Facility | | $22,908.68 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,197.01 / $21,877.62 / $31,622.78
| Professional | | $18,197.01 | $21,877.62 | $31,622.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31,622.78 / $40,738.03 / $48,977.88
| Facility | | $31,622.78 | $40,738.03 | $48,977.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $53,703.18
| Professional | | $4,073.80 | $4,073.80 | $53,703.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30,902.95 / $30,902.95 / $30,902.95
| Professional | | $30,902.95 | $30,902.95 | $30,902.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,703.96 / $25,703.96 / $25,703.96
| Facility | | $25,703.96 | $25,703.96 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25,703.96 / $28,840.32 / $43,651.58
| Professional | | $25,703.96 | $28,840.32 | $43,651.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $19,952.62
| Facility | | $16,595.87 | $16,595.87 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,488.17 / $20,892.96 / $33,884.42
| Professional | | $15,488.17 | $20,892.96 | $33,884.42 |