- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,821.91 / $16,613.00 / $38,041.36
| Facility | | $15,821.91 | $16,613.00 | $38,041.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,497.00 / $15,821.91 / $19,968.25
| Professional | | $13,497.00 | $15,821.91 | $19,968.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,087.50 / $16,087.50 / $16,087.50
| Professional | | $16,087.50 | $16,087.50 | $16,087.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,821.91 / $16,613.00 / $42,648.15
| Facility | | $15,821.91 | $16,613.00 | $42,648.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,821.91 / $15,821.91 / $15,821.91
| Professional | | $15,821.91 | $15,821.91 | $15,821.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $100.00
| Professional | | $30.00 | $30.00 | $100.00 |