- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.11 / $373.11 / $466.39
| Professional | | $373.11 | $373.11 | $466.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $355.56 / $363.26 / $2,025.75
| Facility | | $355.56 | $363.26 | $2,025.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.00 / $5,807.00 / $5,807.00
| Professional | | $547.00 | $5,807.00 | $5,807.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $547.00 / $547.00 / $547.00
| Facility | | $547.00 | $547.00 | $547.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.84 / $353.80 / $1,191.00
| Professional | | $339.84 | $353.80 | $1,191.00 |