- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $204.17 / $1,047.13
| Professional | | $83.18 | $204.17 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $190.55 / $1,047.13
| Professional | | $77.62 | $190.55 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $758.58 / $1,202.26
| Professional | | $107.15 | $758.58 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $794.33 / $1,258.93
| Professional | | $89.13 | $794.33 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $218.78 / $1,230.27
| Professional | | $85.11 | $218.78 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $602.56 / $1,348.96
| Professional | | $102.33 | $602.56 | $1,348.96 |