- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.43 / $1,277.00 / $3,109.00
| Facility | | $151.43 | $1,277.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.52 / $151.43 / $184.10
| Professional | | $125.52 | $151.43 | $184.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.23 / $233.24 / $233.24
| Professional | | $176.23 | $233.24 | $233.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.58 / $221.80 / $274.67
| Professional | | $181.58 | $221.80 | $274.67 |
- 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
- $111.23 / $136.41 / $249.48
| Professional | | $111.23 | $136.41 | $249.48 |