- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,165.95 / $10,232.93
| Facility | | $3,630.78 | $6,165.95 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,090.30 / $3,090.30
| Professional | | $2,511.89 | $3,090.30 | $3,090.30 |
- 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
- $3,019.95 / $3,090.30 / $3,090.30
| Professional | | $3,019.95 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Professional | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,019.95 / $3,467.37
| Professional | | $2,754.23 | $3,019.95 | $3,467.37 |