- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.50 / $309.50 / $386.88
| Professional | | $309.50 | $309.50 | $386.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.58 / $292.08 / $2,025.75
| Facility | | $289.58 | $292.08 | $2,025.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.00 / $5,432.00 / $5,432.00
| Professional | | $456.00 | $5,432.00 | $5,432.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $456.00 / $456.00 / $456.00
| Facility | | $456.00 | $456.00 | $456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.24 / $301.54 / $1,115.00
| Professional | | $282.24 | $301.54 | $1,115.00 |