- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.94 / $1,064.00 / $2,812.00
| Facility | | $223.94 | $1,064.00 | $2,812.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.86 / $721.94 / $1,132.51
| Professional | | $157.86 | $721.94 | $1,132.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.98 / $249.97 / $1,063.49
| Professional | | $169.98 | $249.97 | $1,063.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.64 / $406.75 / $1,490.71
| Professional | | $262.64 | $406.75 | $1,490.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.00 / $337.00 / $768.00
| Facility | | $130.00 | $337.00 | $768.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.48 / $935.21 / $1,578.49
| Professional | | $320.48 | $935.21 | $1,578.49 |