- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,043.01 / $1,043.01 / $1,043.01
| Facility | | $1,043.01 | $1,043.01 | $1,043.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.38 / $795.00 / $1,043.01
| Professional | | $421.38 | $795.00 | $1,043.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.00 / $1,478.00 / $1,478.00
| Professional | | $1,478.00 | $1,478.00 | $1,478.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.60 / $750.60 / $4,321.62
| Professional | | $750.60 | $750.60 | $4,321.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.57 / $62.77 / $229.17
| Professional | | $40.57 | $62.77 | $229.17 |