- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,498.45 / $19,498.45 / $19,498.45
| Facility | | $19,498.45 | $19,498.45 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,488.17 / $16,595.87 / $19,498.45
| Professional | | $15,488.17 | $16,595.87 | $19,498.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,782.79 / $17,782.79 / $17,782.79
| Facility | | $17,782.79 | $17,782.79 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,782.79 / $17,782.79 / $17,782.79
| Professional | | $17,782.79 | $17,782.79 | $17,782.79 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,630.78 / $4,570.88
| Facility | | $3,162.28 | $3,630.78 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $19,498.45
| Professional | | $16,218.10 | $16,218.10 | $19,498.45 |