- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,488.17 / $16,595.87 / $16,595.87
| Professional | | $15,488.17 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,630.78 / $10,000.00
| Facility | | $3,090.30 | $3,630.78 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,595.87 / $16,595.87
| Professional | | $16,218.10 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $16,595.87 / $16,595.87
| Facility | | $4,897.79 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $30,199.52
| Professional | | $16,595.87 | $16,595.87 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $19,952.62
| Professional | | $16,595.87 | $16,595.87 | $19,952.62 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $10,715.19 / $16,218.10 / $23,442.29
| Professional | | $10,715.19 | $16,218.10 | $23,442.29 |