- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,775.00 / $3,775.00 / $14,171.68
| Facility | | $3,775.00 | $3,775.00 | $14,171.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,775.00 / $3,775.00 / $7,961.62
| Professional | | $3,775.00 | $3,775.00 | $7,961.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $11.98
| Professional | | $0.02 | $0.02 | $11.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,775.00 / $5,749.33 / $8,996.62
| Facility | | $3,775.00 | $5,749.33 | $8,996.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,291.00 / $1,291.00 / $4,071.00
| Facility | | $1,291.00 | $1,291.00 | $4,071.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.00 / $1,291.00 / $4,071.00
| Professional | | $1,291.00 | $1,291.00 | $4,071.00 |