- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,608.54 / $16,608.54 / $23,321.00
| Facility | | $16,608.54 | $16,608.54 | $23,321.00 |
- 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
- $15,631.57 / $15,631.57 / $15,631.57
| Professional | | $15,631.57 | $15,631.57 | $15,631.57 |
- 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
- $4,054.85 / $15,778.12 / $18,562.49
| Professional | | $4,054.85 | $15,778.12 | $18,562.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,282.88 / $16,282.88 / $26,390.97
| Professional | | $16,282.88 | $16,282.88 | $26,390.97 |