- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $302.00 / $3,235.94
| Facility | | $199.53 | $302.00 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $288.40 / $562.34
| Professional | | $165.96 | $288.40 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $239.88 / $338.84
| Professional | | $162.18 | $239.88 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $165.96 / $316.23
| Professional | | $117.49 | $165.96 | $316.23 |