- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $226.74 / $1,342.00 / $3,109.00
| Facility | | $226.74 | $1,342.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.74 / $228.72 / $333.61
| Professional | | $226.74 | $228.72 | $333.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.37 / $475.38 / $651.59
| Professional | | $326.37 | $475.38 | $651.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,056.00 / $2,558.00
| Facility | | $375.00 | $1,056.00 | $2,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.69 / $352.72 / $646.27
| Professional | | $260.69 | $352.72 | $646.27 |