- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,631.57 / $15,631.57 / $15,631.57
| Facility | | $15,631.57 | $15,631.57 | $15,631.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,631.57 / $15,631.57 / $18,562.49
| Professional | | $15,631.57 | $15,631.57 | $18,562.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,848.22 / $28,332.21 / $52,105.22
| Facility | | $4,848.22 | $28,332.21 | $52,105.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,697.40 / $16,608.54 / $16,608.54
| Professional | | $7,697.40 | $16,608.54 | $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
- $11,183.86 / $16,217.75 / $28,136.83
| Facility | | $11,183.86 | $16,217.75 | $28,136.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,282.88 / $16,282.88 / $16,282.88
| Professional | | $16,282.88 | $16,282.88 | $16,282.88 |