- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,826.96 / $15,826.96 / $15,826.96
| Facility | | $15,826.96 | $15,826.96 | $15,826.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,631.57 / $15,826.96 / $16,217.75
| Professional | | $15,631.57 | $15,826.96 | $16,217.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,608.54 / $16,608.54 / $16,608.54
| Facility | | $16,608.54 | $16,608.54 | $16,608.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,608.54 / $16,608.54 / $16,608.54
| Professional | | $16,608.54 | $16,608.54 | $16,608.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,314.91 / $16,601.06 / $22,632.55
| Facility | | $4,314.91 | $16,601.06 | $22,632.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,282.88 / $16,282.88 / $19,962.81
| Professional | | $16,282.88 | $16,282.88 | $19,962.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,282.88 / $16,282.88 / $17,259.84
| Professional | | $16,282.88 | $16,282.88 | $17,259.84 |