- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.42 / $382.42 / $478.03
| Professional | | $382.42 | $382.42 | $478.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.66 / $234.15 / $1,524.13
| Facility | | $186.66 | $234.15 | $1,524.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.00 / $5,807.00 / $5,807.00
| Professional | | $228.00 | $5,807.00 | $5,807.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.18 / $130.18 / $228.00
| Facility | | $130.18 | $130.18 | $228.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.18 / $223.14 / $1,595.63
| Professional | | $130.18 | $223.14 | $1,595.63 |