- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $1,621.81
| Professional | | $30.20 | $44.67 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,000.00 / $1,445.44
| Professional | | $645.65 | $1,000.00 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $891.25 / $1,819.70
| Professional | | $660.69 | $891.25 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $60.26 / $75.86
| Professional | | $45.71 | $60.26 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.74 / $1,148.15 / $1,659.59
| Professional | | $40.74 | $1,148.15 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $60.26 / $81.28
| Professional | | $46.77 | $60.26 | $81.28 |