- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $512.86 / $1,148.15
| Facility | | $331.13 | $512.86 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $269.15 / $323.59
| Professional | | $141.25 | $269.15 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $1,000.00
| Facility | | $331.13 | $331.13 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $70.79 / $147.91
| Professional | | $70.79 | $70.79 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $331.13 / $741.31
| Facility | | $213.80 | $331.13 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $302.00 / $602.56
| Professional | | $151.36 | $302.00 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $331.13
| Facility | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $154.88 / $331.13
| Professional | | $138.04 | $154.88 | $331.13 |