- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,106.75 / $4,523.43 / $10,213.90
| Facility | | $3,106.75 | $4,523.43 | $10,213.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,106.75 / $3,106.75 / $3,106.75
| Professional | | $3,106.75 | $3,106.75 | $3,106.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.03
| Facility | | $0.02 | $0.02 | $0.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,045.83 / $3,045.83 / $3,106.75
| Professional | | $3,045.83 | $3,045.83 | $3,106.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,106.75 / $3,106.75 / $3,106.75
| Professional | | $3,106.75 | $3,106.75 | $3,106.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,741.25 / $3,045.83 / $3,429.85
| Professional | | $2,741.25 | $3,045.83 | $3,429.85 |