- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,911.31 / $19,911.31 / $19,911.31
| Facility | | $19,911.31 | $19,911.31 | $19,911.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.11 / $1,480.12 / $2,918.48
| Professional | | $1,480.11 | $1,480.12 | $2,918.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,696.71 / $2,038.08 / $2,984.07
| Professional | | $1,696.71 | $2,038.08 | $2,984.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,890.04 / $2,210.29 / $3,465.45
| Professional | | $1,890.04 | $2,210.29 | $3,465.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.63 / $2,231.48 / $3,423.21
| Professional | | $1,732.63 | $2,231.48 | $3,423.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,911.31 / $19,911.31 / $19,911.31
| Facility | | $19,911.31 | $19,911.31 | $19,911.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.11 / $1,480.12 / $2,918.48
| Professional | | $1,480.11 | $1,480.12 | $2,918.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.41 / $2,162.39 / $3,150.66
| Professional | | $1,493.41 | $2,162.39 | $3,150.66 |