- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,023.05 / $16,023.05 / $18,488.14
| Professional | | $16,023.05 | $16,023.05 | $18,488.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,524.00 / $16,524.00 / $16,524.00
| Facility | | $16,524.00 | $16,524.00 | $16,524.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,062.52 / $16,524.00 / $17,615.41
| Professional | | $12,062.52 | $16,524.00 | $17,615.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,524.00 / $16,524.00 / $16,524.00
| Facility | | $16,524.00 | $16,524.00 | $16,524.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,062.52 / $16,524.00 / $17,615.41
| Professional | | $12,062.52 | $16,524.00 | $17,615.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,363.14 / $19,372.84 / $33,292.81
| Professional | | $9,363.14 | $19,372.84 | $33,292.81 |