- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $831.76
| Facility | | $186.21 | $186.21 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $144.54 / $186.21
| Professional | | $100.00 | $144.54 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $1,174.90 / $1,288.25
| Facility | | $213.80 | $1,174.90 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $120.23 / $186.21
| Professional | | $74.13 | $120.23 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $416.87 / $416.87
| Facility | | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $186.21 / $346.74
| Professional | | $79.43 | $186.21 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $223.87
| Professional | | $186.21 | $186.21 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $302.00
| Facility | | $186.21 | $186.21 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $177.83 / $275.42
| Professional | | $120.23 | $177.83 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $186.21 / $281.84
| Professional | | $112.20 | $186.21 | $281.84 |