- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.77 / $207.43 / $1,180.76
| Professional | | $103.77 | $207.43 | $1,180.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.03 / $184.03 / $360.17
| Professional | | $184.03 | $184.03 | $360.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.07 / $236.96 / $506.78
| Professional | | $126.07 | $236.96 | $506.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.30 / $295.10 / $579.53
| Professional | | $155.30 | $295.10 | $579.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.64 / $364.81 / $437.57
| Professional | | $294.64 | $364.81 | $437.57 |