- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.56 / $588.91 / $1,060.73
| Professional | | $103.56 | $588.91 | $1,060.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.58 / $706.09 / $1,169.26
| Professional | | $107.58 | $706.09 | $1,169.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.23 / $541.06 / $672.06
| Professional | | $424.23 | $541.06 | $672.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.01 / $190.14 / $1,549.14
| Professional | | $117.01 | $190.14 | $1,549.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $678.76 / $845.97 / $1,518.48
| Professional | | $678.76 | $845.97 | $1,518.48 |