- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.77 / $973.77 / $3,822.00
| Professional | | $973.77 | $973.77 | $3,822.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $68.80 / $270.13 / $450.12
| Facility | | $68.80 | $270.13 | $450.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.62 / $68.80 / $79.98
| Professional | | $57.62 | $68.80 | $79.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $973.77 / $3,822.00 / $5,465.46
| Facility | | $973.77 | $3,822.00 | $5,465.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,420.02 / $1,420.02 / $1,420.02
| Professional | | $1,420.02 | $1,420.02 | $1,420.02 |