- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.80 / $278.92 / $3,109.00
| Facility | | $125.80 | $278.92 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.13 / $164.52 / $271.77
| Professional | | $102.13 | $164.52 | $271.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.97 / $149.96 / $266.92
| Professional | | $101.97 | $149.96 | $266.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $132.01
| Facility | | $120.36 | $120.36 | $132.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.35 / $205.13 / $343.53
| Professional | | $111.35 | $205.13 | $343.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.71 / $221.59 / $410.07
| Professional | | $178.71 | $221.59 | $410.07 |