- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,036.35 / $3,036.35 / $3,271.93
| Facility | | $3,036.35 | $3,036.35 | $3,271.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.57 / $1,009.78 / $1,112.45
| Professional | | $875.57 | $1,009.78 | $1,112.45 |
- 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
- $1,112.45 / $1,112.45 / $1,156.08
| Professional | | $1,112.45 | $1,112.45 | $1,156.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,001.02 / $1,001.02 / $1,001.02
| Facility | | $1,001.02 | $1,001.02 | $1,001.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.59 / $1,427.38 / $4,186.17
| Professional | | $1,271.59 | $1,427.38 | $4,186.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,036.35 / $3,036.35 / $3,271.93
| Facility | | $3,036.35 | $3,036.35 | $3,271.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.57 / $1,009.78 / $1,112.45
| Professional | | $875.57 | $1,009.78 | $1,112.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.08 / $1,308.77 / $1,897.72
| Professional | | $1,156.08 | $1,308.77 | $1,897.72 |