- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $371.54 / $1,122.02
| Facility | | $281.84 | $371.54 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $295.12 / $426.58
| Professional | | $251.19 | $295.12 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Professional | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $1,000.00
| Facility | | $245.47 | $245.47 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $416.87 / $501.19
| Professional | | $416.87 | $416.87 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $371.54 / $645.65
| Facility | | $275.42 | $371.54 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $158.49 / $562.34
| Professional | | $158.49 | $158.49 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Facility | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $158.49 / $245.47
| Professional | | $158.49 | $158.49 | $245.47 |