- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,378.01 / $17,378.01 / $17,378.01
| Facility | | $17,378.01 | $17,378.01 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,620.87 / $23,442.29 / $40,738.03
| Professional | | $18,620.87 | $23,442.29 | $40,738.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31,622.78 / $31,622.78 / $47,863.01
| Facility | | $31,622.78 | $31,622.78 | $47,863.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,908.68 / $22,908.68 / $31,622.78
| Professional | | $22,908.68 | $22,908.68 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31,622.78 / $50,118.72 / $69,183.10
| Professional | | $31,622.78 | $50,118.72 | $69,183.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46,773.51 / $46,773.51 / $46,773.51
| Professional | | $46,773.51 | $46,773.51 | $46,773.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,183.83 / $46,773.51 / $58,884.37
| Facility | | $28,183.83 | $46,773.51 | $58,884.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,379.62 / $25,118.86 / $38,904.51
| Professional | | $21,379.62 | $25,118.86 | $38,904.51 |