- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $423.83 / $423.83 / $529.79
| Professional | | $423.83 | $423.83 | $529.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $344.15 / $431.72 / $1,300.00
| Facility | | $344.15 | $431.72 | $1,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.00 / $2,154.00 / $2,154.00
| Professional | | $373.00 | $2,154.00 | $2,154.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.08 / $239.08 / $373.00
| Facility | | $239.08 | $239.08 | $373.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.08 / $387.00 / $419.00
| Professional | | $239.08 | $387.00 | $419.00 |