- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,952.62 / $19,952.62 / $19,952.62
| Facility | | $19,952.62 | $19,952.62 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,288.25 / $3,388.44
| Professional | | $1,023.29 | $1,288.25 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,548.82 / $2,137.96
| Professional | | $977.24 | $1,548.82 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,445.44 / $2,454.71
| Professional | | $1,288.25 | $1,445.44 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,479.11 / $2,187.76
| Professional | | $1,202.26 | $1,479.11 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,952.62 / $19,952.62 / $19,952.62
| Facility | | $19,952.62 | $19,952.62 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,479.11 / $3,388.44
| Professional | | $1,071.52 | $1,479.11 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,548.82 / $2,454.71
| Professional | | $1,148.15 | $1,548.82 | $2,454.71 |