- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,753.34 / $3,753.34 / $4,044.55
| Facility | | $3,753.34 | $3,753.34 | $4,044.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.15 / $1,375.15 / $1,375.15
| Professional | | $1,375.15 | $1,375.15 | $1,375.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.03 / $0.03 / $0.03
| Facility | | $0.03 | $0.03 | $0.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Professional | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Facility | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Professional | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,730.60
| Professional | | $1,429.07 | $1,429.07 | $1,730.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,753.34 / $3,753.34 / $4,044.55
| Facility | | $3,753.34 | $3,753.34 | $4,044.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.15 / $1,375.15 / $4,044.55
| Professional | | $1,375.15 | $1,375.15 | $4,044.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.63 / $1,388.63 / $2,082.94
| Professional | | $1,388.63 | $1,388.63 | $2,082.94 |