- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.40 / $151.41 / $703.77
| Professional | | $111.40 | $151.41 | $703.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.93 / $954.72 / $1,997.19
| Professional | | $809.93 | $954.72 | $1,997.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.43 / $313.86 / $1,362.65
| Professional | | $174.43 | $313.86 | $1,362.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.43 / $262.50 / $1,328.29
| Professional | | $174.43 | $262.50 | $1,328.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.79 / $1,005.20 / $2,451.33
| Professional | | $542.79 | $1,005.20 | $2,451.33 |