- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.09 / $224.67 / $724.02
| Professional | | $133.09 | $224.67 | $724.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.80 / $897.10 / $2,600.96
| Professional | | $750.80 | $897.10 | $2,600.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.18 / $788.86 / $2,124.14
| Professional | | $228.18 | $788.86 | $2,124.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.46 / $788.86 / $1,736.50
| Professional | | $232.46 | $788.86 | $1,736.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.14 / $993.15 / $3,192.39
| Professional | | $822.14 | $993.15 | $3,192.39 |