- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.46 / $394.19 / $6,896.43
| Professional | | $178.46 | $394.19 | $6,896.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.00 / $1,200.00 / $1,200.00
| Professional | | $1,200.00 | $1,200.00 | $1,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.06 / $4,049.23 / $7,853.36
| Professional | | $265.06 | $4,049.23 | $7,853.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,537.58 / $4,658.45 / $9,017.70
| Professional | | $3,537.58 | $4,658.45 | $9,017.70 |