- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,631.57 / $15,631.57 / $15,631.57
| Facility | | $15,631.57 | $15,631.57 | $15,631.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,631.57 / $15,631.57 / $16,608.54
| Professional | | $15,631.57 | $15,631.57 | $16,608.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,611.56 / $24,254.98 / $43,131.72
| Facility | | $17,611.56 | $24,254.98 | $43,131.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,468.74 / $16,282.88 / $19,539.46
| Professional | | $15,468.74 | $16,282.88 | $19,539.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,520.26 / $16,608.54 / $16,608.54
| Professional | | $4,520.26 | $16,608.54 | $16,608.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,631.57 / $17,576.37 / $19,539.46
| Facility | | $15,631.57 | $17,576.37 | $19,539.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,631.57 / $17,259.84 / $20,711.82
| Professional | | $15,631.57 | $17,259.84 | $20,711.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $55.00
| Professional | | $30.00 | $30.00 | $55.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,282.88 / $16,282.88 / $19,539.46
| Professional | | $16,282.88 | $16,282.88 | $19,539.46 |