- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.32 / $2,038.01 / $8,870.40
| Facility | | $402.32 | $2,038.01 | $8,870.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $4,972.50
| Professional | | $402.32 | $402.32 | $4,972.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.97 / $1.00 / $1.00
| Facility | | $0.97 | $1.00 | $1.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.93 / $1,054.93 / $1,054.93
| Professional | | $1,054.93 | $1,054.93 | $1,054.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.32 / $414.39 / $1,736.00
| Facility | | $402.32 | $414.39 | $1,736.00 |