- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,320.00 / $16,320.00 / $16,320.00
| Facility | | $16,320.00 | $16,320.00 | $16,320.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,936.00 / $16,320.00 / $16,320.00
| Professional | | $15,936.00 | $16,320.00 | $16,320.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,638.40 / $17,638.40 / $17,638.40
| Facility | | $17,638.40 | $17,638.40 | $17,638.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,638.40 / $17,638.40 / $17,638.40
| Professional | | $17,638.40 | $17,638.40 | $17,638.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,320.00 / $16,960.00 / $24,910.83
| Facility | | $16,320.00 | $16,960.00 | $24,910.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,320.00 / $16,320.00 / $16,960.00
| Professional | | $16,320.00 | $16,320.00 | $16,960.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,412.50 / $19,200.00 / $19,200.00
| Professional | | $6,412.50 | $19,200.00 | $19,200.00 |