- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $23,988.33
| Facility | | $16,595.87 | $16,595.87 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,489.63 / $15,848.93 / $16,595.87
| Professional | | $13,489.63 | $15,848.93 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,488.17 / $15,488.17 / $15,488.17
| Professional | | $15,488.17 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $16,595.87
| Facility | | $16,595.87 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $16,595.87
| Professional | | $16,595.87 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $15,848.93 / $18,620.87
| Professional | | $4,168.69 | $15,848.93 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $26,302.68
| Professional | | $16,218.10 | $16,218.10 | $26,302.68 |