- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.83 / $610.80 / $1,040.79
| Professional | | $92.83 | $610.80 | $1,040.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.80 / $123.29 / $1,018.31
| Professional | | $104.80 | $123.29 | $1,018.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.24 / $703.02 / $1,342.08
| Professional | | $97.24 | $703.02 | $1,342.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.43 / $1,056.28 / $4,774.08
| Professional | | $759.43 | $1,056.28 | $4,774.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $732.51 / $865.51 / $1,543.84
| Professional | | $732.51 | $865.51 | $1,543.84 |