- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.59 / $225.36 / $1,102.49
| Professional | | $78.59 | $225.36 | $1,102.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.71 / $213.24 / $620.00
| Professional | | $95.71 | $213.24 | $620.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.62 / $544.50 / $1,371.30
| Professional | | $217.62 | $544.50 | $1,371.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.20 / $532.71 / $1,124.20
| Professional | | $283.20 | $532.71 | $1,124.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.25 / $448.40 / $1,022.00
| Professional | | $176.25 | $448.40 | $1,022.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.14 / $503.00 / $1,368.14
| Professional | | $258.14 | $503.00 | $1,368.14 |