- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,148.15
| Professional | | $1,047.13 | $1,047.13 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.42 / $281.84 / $371.54
| Facility | | $234.42 | $281.84 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,047.13 / $1,047.13
| Facility | | $1,000.00 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $851.14 / $1,000.00
| Professional | | $125.89 | $851.14 | $1,000.00 |