- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.63 / $758.63 / $948.29
| Professional | | $758.63 | $758.63 | $948.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.16 / $465.47 / $4,815.68
| Facility | | $375.16 | $465.47 | $4,815.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $466.00 / $5,807.00 / $5,807.00
| Professional | | $466.00 | $5,807.00 | $5,807.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $258.02 / $258.02 / $466.00
| Facility | | $258.02 | $258.02 | $466.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.02 / $446.95 / $4,198.00
| Professional | | $258.02 | $446.95 | $4,198.00 |