- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,450.56 / $24,450.56 / $24,450.56
| Facility | | $24,450.56 | $24,450.56 | $24,450.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,295.74 / $24,450.56 / $36,619.33
| Professional | | $15,295.74 | $24,450.56 | $36,619.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48,901.12 / $54,945.30 / $99,758.28
| Facility | | $48,901.12 | $54,945.30 | $99,758.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27,870.24 / $27,870.24 / $30,099.86
| Professional | | $27,870.24 | $27,870.24 | $30,099.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31,290.51 / $31,290.51 / $31,290.51
| Facility | | $31,290.51 | $31,290.51 | $31,290.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,842.07 / $22,842.07 / $51,503.87
| Professional | | $22,842.07 | $22,842.07 | $51,503.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,917.11 / $24,450.56 / $64,979.66
| Facility | | $13,917.11 | $24,450.56 | $64,979.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,917.11 / $13,917.11 / $13,917.11
| Professional | | $13,917.11 | $13,917.11 | $13,917.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35,697.82 / $61,126.40 / $96,824.22
| Professional | | $35,697.82 | $61,126.40 | $96,824.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,931.61 / $21,557.44 / $33,219.35
| Professional | | $19,931.61 | $21,557.44 | $33,219.35 |