- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.71 / $495.81 / $1,169.44
| Professional | | $91.71 | $495.81 | $1,169.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.40 / $213.25 / $1,412.52
| Professional | | $103.40 | $213.25 | $1,412.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.26 / $325.35 / $1,926.14
| Professional | | $98.26 | $325.35 | $1,926.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.52 / $359.26 / $1,917.04
| Professional | | $105.52 | $359.26 | $1,917.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.71 / $201.80 / $1,169.44
| Professional | | $91.71 | $201.80 | $1,169.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.95 / $1,302.52 / $1,968.04
| Professional | | $762.95 | $1,302.52 | $1,968.04 |