- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.05 / $336.05 / $3,008.00
| Professional | | $336.05 | $336.05 | $3,008.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,827.47 / $1,827.47 / $1,827.47
| Professional | | $1,827.47 | $1,827.47 | $1,827.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $405.00 / $405.00 / $413.10
| Facility | | $405.00 | $405.00 | $413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.25 / $405.00 / $750.00
| Professional | | $344.25 | $405.00 | $750.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $336.05 / $352.85 / $1,236.00
| Facility | | $336.05 | $352.85 | $1,236.00 |