- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $660.69 / $1,148.15
| Professional | | $165.96 | $660.69 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $501.19 / $758.58
| Professional | | $123.03 | $501.19 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $724.44
| Professional | | $676.08 | $676.08 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $263.03 / $549.54
| Professional | | $199.53 | $263.03 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $870.96 / $1,148.15
| Professional | | $158.49 | $870.96 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $1,000.00 / $1,621.81
| Professional | | $218.78 | $1,000.00 | $1,621.81 |