- 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
- $470.54 / $858.36 / $1,043.01
| Professional | | $470.54 | $858.36 | $1,043.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.00 / $2,100.00 / $2,100.00
| Professional | | $2,100.00 | $2,100.00 | $2,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.45 / $750.60 / $4,077.00
| Professional | | $79.45 | $750.60 | $4,077.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.57 / $62.77 / $779.90
| Professional | | $40.57 | $62.77 | $779.90 |