- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $19,952.62
| Facility | | $16,595.87 | $16,595.87 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,489.63 / $16,595.87 / $16,595.87
| Professional | | $13,489.63 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $12,302.69 / $33,884.42
| Facility | | $4,466.84 | $12,302.69 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,595.87 / $19,054.61
| Professional | | $16,218.10 | $16,595.87 | $19,054.61 |
- 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
- $16,595.87 / $16,595.87 / $31,622.78
| Professional | | $16,595.87 | $16,595.87 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $16,595.87
| Professional | | $16,218.10 | $16,218.10 | $16,595.87 |