- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,946.17 / $22,946.17 / $22,946.17
| Facility | | $22,946.17 | $22,946.17 | $22,946.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20,545.34 / $21,290.31 / $22,993.53
| Professional | | $20,545.34 | $21,290.31 | $22,993.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36,588.73 / $47,211.27 / $54,014.41
| Facility | | $36,588.73 | $47,211.27 | $54,014.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27,574.65 / $27,870.24 / $27,870.24
| Professional | | $27,574.65 | $27,870.24 | $27,870.24 |
- 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 / $31,290.51
| Professional | | $22,842.07 | $22,842.07 | $31,290.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30,687.33 / $30,687.33 / $30,687.33
| Facility | | $30,687.33 | $30,687.33 | $30,687.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30,687.33 / $30,687.33 / $43,434.37
| Professional | | $30,687.33 | $30,687.33 | $43,434.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34,466.03 / $34,466.03 / $34,466.03
| Professional | | $34,466.03 | $34,466.03 | $34,466.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,974.56 / $23,553.19 / $33,219.35
| Professional | | $17,974.56 | $23,553.19 | $33,219.35 |