- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,168.69 / $5,754.40
| Facility | | $3,890.45 | $4,168.69 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,981.07 / $4,786.30
| Professional | | $3,890.45 | $3,981.07 | $4,786.30 |
- 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
- $4,786.30 / $4,786.30 / $6,025.60
| Professional | | $4,786.30 | $4,786.30 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $5,248.07
| Professional | | $4,786.30 | $4,786.30 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,677.35 / $8,912.51
| Facility | | $3,890.45 | $4,677.35 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,025.60 / $6,760.83
| Professional | | $5,128.61 | $6,025.60 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $5,623.41
| Facility | | $5,623.41 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,623.41 / $6,309.57
| Professional | | $5,128.61 | $5,623.41 | $6,309.57 |