- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.63 / $305.63 / $382.03
| Professional | | $305.63 | $305.63 | $382.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $285.95 / $289.10 / $2,070.00
| Facility | | $285.95 | $289.10 | $2,070.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $452.00 / $6,266.00 / $6,266.00
| Professional | | $452.00 | $6,266.00 | $6,266.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $452.00 / $452.00 / $452.00
| Facility | | $452.00 | $452.00 | $452.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.83 / $298.86 / $1,114.00
| Professional | | $278.83 | $298.86 | $1,114.00 |