- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.27 / $2,114.64 / $4,000.00
| Professional | | $1,609.27 | $2,114.64 | $4,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $178.78 / $645.83 / $1,167.63
| Facility | | $178.78 | $645.83 | $1,167.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.04
| Professional | | $0.02 | $0.02 | $0.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,609.27 / $1,609.27 / $4,400.00
| Facility | | $1,609.27 | $1,609.27 | $4,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.27 / $1,609.27 / $1,609.27
| Professional | | $1,609.27 | $1,609.27 | $1,609.27 |