- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.73 / $1,342.00 / $3,109.00
| Facility | | $172.73 | $1,342.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.73 / $173.15 / $265.77
| Professional | | $172.73 | $173.15 | $265.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.34 / $196.34 / $196.34
| Professional | | $148.34 | $196.34 | $196.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.36 / $358.40 / $444.23
| Professional | | $226.36 | $358.40 | $444.23 |
- 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
- $143.93 / $206.83 / $301.04
| Professional | | $143.93 | $206.83 | $301.04 |