- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30,695.25 / $30,695.25 / $30,695.25
| Facility | | $30,695.25 | $30,695.25 | $30,695.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30,695.25 / $30,695.25 / $36,192.90
| Professional | | $30,695.25 | $30,695.25 | $36,192.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42,304.45 / $46,534.91 / $47,004.95
| Professional | | $42,304.45 | $46,534.91 | $47,004.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31,290.51 / $52,946.39 / $52,946.39
| Facility | | $31,290.51 | $52,946.39 | $52,946.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31,290.51 / $52,946.39 / $81,644.42
| Professional | | $31,290.51 | $52,946.39 | $81,644.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,233.94 / $52,181.93 / $225,247.51
| Facility | | $24,233.94 | $52,181.93 | $225,247.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,325.52 / $28,486.86 / $40,021.78
| Professional | | $18,325.52 | $28,486.86 | $40,021.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52,791.47 / $52,946.39 / $66,710.62
| Facility | | $52,791.47 | $52,946.39 | $66,710.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43,363.37 / $62,573.00 / $109,078.20
| Professional | | $43,363.37 | $62,573.00 | $109,078.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,325.52 / $24,013.07 / $33,219.35
| Professional | | $18,325.52 | $24,013.07 | $33,219.35 |