- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.00 / $1,060.57 / $1,060.57
| Professional | | $765.00 | $1,060.57 | $1,060.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $336.00 / $445.00 / $717.00
| Facility | | $336.00 | $445.00 | $717.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $752.00 / $752.00 / $752.00
| Facility | | $752.00 | $752.00 | $752.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $993.59 / $1,060.57 / $1,802.97
| Facility | | $993.59 | $1,060.57 | $1,802.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |