- 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
- $16,608.50 / $16,608.54 / $16,608.54
| Professional | | $16,608.50 | $16,608.54 | $16,608.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,465.93 / $24,753.23 / $48,807.93
| Facility | | $4,465.93 | $24,753.23 | $48,807.93 |
- 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 |
- 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
- 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
- Professional
- Modifier
- Low / Median / High Price
- $16,282.88 / $16,282.88 / $17,976.30
| Professional | | $16,282.88 | $16,282.88 | $17,976.30 |