- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.85 / $861.81 / $1,016.87
| Facility | | $156.85 | $861.81 | $1,016.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.89 / $133.00 / $159.21
| Professional | | $120.89 | $133.00 | $159.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.41 / $192.39 / $294.02
| Professional | | $158.41 | $192.39 | $294.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.87 / $125.86 / $153.12
| Professional | | $95.87 | $125.86 | $153.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.86 / $195.78 / $248.46
| Professional | | $151.86 | $195.78 | $248.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.84 / $170.28 / $243.81
| Professional | | $123.84 | $170.28 | $243.81 |