- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,217.75 / $16,608.50 / $16,608.54
| Facility | | $16,217.75 | $16,608.50 | $16,608.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,631.57 / $16,217.75 / $16,608.54
| Professional | | $15,631.57 | $16,217.75 | $16,608.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,465.93 / $15,499.16 / $29,309.18
| Facility | | $4,465.93 | $15,499.16 | $29,309.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,834.59 / $16,282.88 / $16,608.54
| Professional | | $7,834.59 | $16,282.88 | $16,608.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,608.54 / $16,608.54 / $16,608.54
| Facility | | $16,608.54 | $16,608.54 | $16,608.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,608.54 / $16,608.54 / $16,608.54
| Professional | | $16,608.54 | $16,608.54 | $16,608.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,273.74 / $18,273.74 / $18,273.74
| Facility | | $18,273.74 | $18,273.74 | $18,273.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,282.88 / $16,282.88 / $19,539.46
| Professional | | $16,282.88 | $16,282.88 | $19,539.46 |