- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.60 / $799.14 / $1,555.49
| Professional | | $537.60 | $799.14 | $1,555.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.00 / $1,211.00 / $1,211.00
| Professional | | $1,211.00 | $1,211.00 | $1,211.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $711.86 / $1,041.04 / $1,518.07
| Professional | | $711.86 | $1,041.04 | $1,518.07 |
- 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
- $675.98 / $890.17 / $1,757.92
| Professional | | $675.98 | $890.17 | $1,757.92 |