- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.63 / $495.81 / $1,113.32
| Professional | | $78.63 | $495.81 | $1,113.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.33 / $1,323.44 / $2,281.44
| Professional | | $168.33 | $1,323.44 | $2,281.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.51 / $268.85 / $2,447.64
| Professional | | $103.51 | $268.85 | $2,447.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.68 / $1,717.92 / $6,893.12
| Professional | | $866.68 | $1,717.92 | $6,893.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $747.50 / $1,555.30 / $2,213.84
| Professional | | $747.50 | $1,555.30 | $2,213.84 |