- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.41 / $187.41 / $1,301.52
| Professional | | $187.41 | $187.41 | $1,301.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.10 / $209.46 / $1,014.59
| Professional | | $157.10 | $209.46 | $1,014.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.66 / $262.58 / $414.57
| Professional | | $152.66 | $262.58 | $414.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.02 / $190.37 / $1,317.18
| Professional | | $169.02 | $190.37 | $1,317.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.02 / $187.47 / $383.31
| Professional | | $169.02 | $187.47 | $383.31 |