- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.78 / $255.44 / $1,696.11
| Professional | | $109.78 | $255.44 | $1,696.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.55 / $586.59 / $1,829.09
| Professional | | $107.55 | $586.59 | $1,829.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.87 / $835.77 / $1,687.82
| Professional | | $119.87 | $835.77 | $1,687.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.58 / $1,043.03 / $1,043.03
| Professional | | $1,025.58 | $1,043.03 | $1,043.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.92 / $1,266.59 / $2,430.02
| Professional | | $720.92 | $1,266.59 | $2,430.02 |